[Prevention of adverse events for patient safety in chronic pain treatment units]. / Prevención de eventos adversos para la seguridad del paciente en las unidades de tratamiento del dolor crónico.

OBJECTIVES: To identify preventive actions that minimise risk of patients safety in pain treatment units, and to cluster preventive actions into homogeneous groups. The current study is part of a project intended to improve patient safety in pain treatment units, and is aimed at identifying, prioritising and preventing patient safety risk. MATERIAL AND METHODS: A group of experts was selected from professionals with a specific clinical background and experience in pain treatment units. This group was provided with information on patient safety and on known adverse events, errors and related causes. Through a brainstorming method the participants were asked: What changes or improvements would need to be undertaken to absolutely prevent the occurrence of each adverse event? The participant's proposals were analysed and grouped according to their homogeneity. RESULTS: A total of 456 preventive actions were identified. The group that received the highest number of suggestions was the one including changes in the management of healthcare processes, followed by the group that considered improvements in clinical practice, training activities, protocols and policies, and patient communication. CONCLUSIONS: According to the consensus of the experts, management of healthcare processes and improvements in health care practices are the 2 interventions that are most likely to reduce patient safety risk in pain treatment units.

Identificación y priorización de episodios adversos y fallos relacionados con la seguridad del paciente en las Unidades de Tratamiento del Dolor / Identifying and prioritising adverse episodes and failures related to patient safety in Pain Treatment Units

Objetivos. Un grupo de expertos coordinado por la Escuela Andaluza de Salud Pública identificó los episodios adversos (EA) más graves y frecuentes en las Unidades de Tratamiento del Dolor (UTD), así como los fallos y las causas subyacentes, como paso previo a la elaboración de acciones preventivas. Los objetivos del proyecto fueron identificar los episodios adversos potenciales en las UTD, identificar sus fallos y las causas que pueden originarlos y, priorizar dichos fallos según la herramienta análisis de modos de fallos y de sus efectos (AMFE). Material y métodos. La metodología empleada consistió en realizar una búsqueda bibliográfica, selección de un grupo de expertos con experiencia en UTD, creación de un catálogo de episodios adversos mediante la técnica de generación de ideas y, puesta en práctica de las herramientas AMFE e índice de prioridad de riesgo. Resultados. Se identificaron hasta 66 tipos de episodios adversos relacionados con medicación (30), técnicas invasivas (15), proceso asistencial (10), información y educación del paciente (6), práctica clínica (5). Se localizó que hasta 101 fallos pueden desencadenar esos EA y, que 242 causas pueden provocar esos fallos. Conclusiones. Los resultados indican la necesidad de trabajar principalmente en 2 sentidos: la mejora del proceso asistencial en las UTD (la organización de la asistencia), y el trabajo profesional; este último en 2 aspectos, mejora de la práctica clínica y aumento de las competencias profesionales mediante formación específica. La comunicación, ya sea interprofesional o interservicios o con el paciente y su familia, se identifica como un aspecto clave para la mejora(AU)

Objectives. An expert group coordinated by the Andalusian School of Public Health identified the most serious and frequent adverse events in Pain Treatment Units (PTU), as well the failures and underlying causes, as a prior step to preparing preventive actions. The aims of the project were to identify potential adverse events in Pain Treatment Units, identify failures and their underlying causes, and prioritise these failures according to a failure modes and effects analysis (FMEA) tool. Material and methods. The method employed consisted of a literature search, the selection of an expert group with experience in PTU, creating a catalogue of adverse events using the generation of ideas technique, and putting the FMEA and Risk Priority Index tools into practice. Results. Up to 66 types of adverse events were identified associated with; medication (30), invasive techniques (15), care process (10), patient information and education (6), and clinical practice (5). It was found that up to 101 failures could be triggered by these adverse events, and that 242 causes could lead to these failures. Conclusions. The results indicated the need to work principally in two directions, improving the care process in the PTU (the health care organisation), and the professional work, this latter having two aspects, improving the clinical practice, and increase professional skills by means of specific training. Communication, whether inter-professional or inter-department, or with the patient and their family, is identified as a key aspect for improvement(AU)

[Identifying and prioritising adverse episodes and failures related to patient safety in Pain Treatment Units]. / Identificación y priorización de episodios adversos y fallos relacionados con la seguridad del paciente en las Unidades de Tratamiento del Dolor.

OBJECTIVES: An expert group coordinated by the Andalusian School of Public Health identified the most serious and frequent adverse events in Pain Treatment Units (PTU), as well the failures and underlying causes, as a prior step to preparing preventive actions. The aims of the project were to identify potential adverse events in Pain Treatment Units, identify failures and their underlying causes, and prioritise these failures according to a failure modes and effects analysis (FMEA) tool. MATERIAL AND METHODS: The method employed consisted of a literature search, the selection of an expert group with experience in PTU, creating a catalogue of adverse events using the generation of ideas technique, and putting the FMEA and Risk Priority Index tools into practice. RESULTS: Up to 66 types of adverse events were identified associated with; medication (30), invasive techniques (15), care process (10), patient information and education (6), and clinical practice (5). It was found that up to 101 failures could be triggered by these adverse events, and that 242 causes could lead to these failures. CONCLUSIONS: The results indicated the need to work principally in two directions, improving the care process in the PTU (the health care organisation), and the professional work, this latter having two aspects, improving the clinical practice, and increase professional skills by means of specific training. Communication, whether inter-professional or inter-department, or with the patient and their family, is identified as a key aspect for improvement.