[Impact of the COVID-19 pandemic on patient safety incident and medication error reporting systems]. / Impacto de la pandemia COVID-19 en los sistemas de notificación de incidentes de seguridad del paciente y errores de medicación.

BACKGROUND AND AIM: To determine the impact of the COVID-19 pandemic on the epidemiology of safety incidents (SI) and medication errors (ME) reported to the CISEMadrid notification system in the hospital and primary care settings of the Madrid Health Service (SERMAS). MATERIALS AND METHODS: Observational and descriptive study with a retrospective analysis of data including all CISEMadrid notifications from 01-Jan-2018 to 31-Dec-2020, from 33 hospitals and 262 health care centres of the SERMAS. The two periods in 2020 with the greatest increase in COVID-19 cases were identified to compare incidents reported in the pre-pandemic and pandemic periods. RESULTS: 36,494 incidents were reported. Comparing both periods, an overall decrease in pandemic notifications of 60.7% was observed, being higher in primary care, falling to 33% of previous levels. The reduction in notifications was similar in the peaks and valleys of the waves. The three most frequent SIs in both periods and care settings were: diagnostic tests, medical devices/equipment/clinical furniture and organisational management/citations. In ME, dose failure and inappropriate selection were the most frequent in both settings and periods. There were no relevant differences in patient consequences in both periods. CONCLUSIONS: During the pandemic, patient safety notifications decreased although the most frequent types remained the same, as did their impact on the patient, both in hospitals and in primary care. The safety culture of organisations is a critical aspect for the maintenance of reporting systems.

[Evaluation of effectiveness of corrective measures arising from incident notifications in a paediatric emergency department]. / Evaluación de la efectividad de acciones correctivas derivadas de la notificación de incidentes en urgencias pediátricas.

OBJECTIVE: To analyse the effectiveness of corrective measures arising from the analysis of safety incident notifications in the Paediatric Emergency Unit. METHODS: A quasi-experimental, prospective, and single-centre study was carried out between 2015 and 2018. In the first phase, incidents notified throughout one year were analysed. Corrective measures were then implemented for 5 specific kinds of incidents. These incidents were finally compared to those notified within 12 months after the implementation of those measures. Results were expressed as relative risk and relative risk reduction. RESULTS: A total of 1587 safety incidents were notified (0.9% of patients treated) between January 2015 and December 2017. After implementation of corrective measures, there was a decrease in all kinds of incidents notifications analysed. The incidents related to patient identification were reduced by 60.9% (RR 0.39, 95% CI; 0.25-0.60), and those regarding communication between professionals were reduced by 74.5% (RR 0.25, 95% CI; 0.12-0.55). Incidents related to sedation and analgesic procedures totally disappeared. No significant reduction was found in incidents concerning the triage system, or in those related to rapid intravenous rehydration procedures. CONCLUSIONS: The implementation of improvement actions arising from the analysis of voluntary notification of incidents is an effective strategy to improve patient effective strategy to improve.

[Impact of a strategy to improve the quality of care and risk management in a paediatric emergency department]. / Impacto de una estrategia de mejora de calidad asistencial y gestión de riesgos en un servicio de urgencias pediátricas.

INTRODUCTION: Emergency departments are a high risk area for the occurrence of adverse events. The aim of this study is to analyse the impact of a strategy to improve the quality assurance and risk management in the notification of incidents in our Unit, and describe the improvement actions developed from the reported incidents. MATERIAL AND METHODS: A retrospective observational study was developed during one year, divided into two periods: P1 (Start: training session and implementation of the risk management process), and P2 (Start: feed-back session of incidents reported in P1 and improvement actions developed). In each period, the number of reported incidents in relation to the number of emergencies attended (‰) and the descriptive data of each incident were recorded. The improvement actions developed from the incidents reported in P1 were described. RESULTS: The number of notifications from P1 (4.1‰; 95%CI 3.2-5.0‰) increased in P2 (10.9‰; 95%CI 9.8-10.2‰, P<.001). The most frequent incidents in P1 were medication (33.3%), and identification errors (25.9%): both were significantly reduced in P2 (16.9%, P=.001 and 9.3%, P<.001, respectively). In P2, prescription errors of the P1 were reduced (35.9% vs 62.9%, P=.02). The factors of "Knowledge and training" (23.5%) were the most frequent in P1, decreasing in P2 (7.4%, P<.001). CONCLUSION: It is considered that the implementation of a risk management process, and the promotion of a safety culture, through training and feed-back sessions to all professionals, contributed to increase the volume of notifications in our Unit. The voluntary and anonymous reporting of incidents is useful to identify risks, and plan corrective measures, contributing to improve quality assurance and patient safety.