El movimiento por la Seguridad del Paciente: Caminando hacia una Acción Global / No disponible

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Si ocurrió un evento adverso piense en decir 'lo siento' / In case of an adverse event don’t forget to say sorry

Fundamento. La información al paciente víctima de un evento adverso (EA) presenta ciertas particularidades en función del marco legal del país en el que se produzca, especialmente en lo referido al ofrecimiento de una disculpa. En el presente trabajo se pretende establecer los límites y las condiciones que debemos considerar a la hora de trasladar una disculpa al paciente que ha sufrido un EA. Método. Conferencia de consenso entre 26 profesionales de distintas comunidades autónomas, instituciones y perfiles profesionales con experiencia acreditada en la gestión de sistemas de Seguridad del Paciente y Derecho Penal de diferentes ámbitos laborales (sanidad, aseguradoras, inspección, académico) (AU)

Background. Disclosing information to a patient who is a victim of an adverse event (AE) presents some particularities depending on the legal framework in the country where the AE occurred. The aim of this study is to identify the limits and conditions when apologizing to a patient who has suffered an AE. Methods. A consensus conference involving 26 professionals from different autonomous communities, institutions, and profiles (health, insurance, inspection, academic) with accredited experience in patient safety management systems and criminal law (AU)

Red Europea de Seguridad del Paciente y Calidad (Eupean Network for Patient Safety and Quality of Care). Desarrollo y resultados preliminares en Europa y en el Sistema Nacional de Salud / European Union Network for Patient Safety and Quality of Care (PASQ). Development and preliminary results in Europe and in the Spanish National Health System

Antecedentes: La acción cooperativa conocida como European Union Network for Patient Safety and Quality of Care (PaSQ) pretende promover la seguridad del paciente (SP) en la Unión Europea (UE) y facilitar el intercambio de experiencias entre los Estados Miembros y otras organizaciones interesadas en aspectos relacionados con la calidad asistencial (CA), la SP y la participación de los pacientes. En este artículo se presentan el desarrollo y los resultados preliminares de esta iniciativa, especialmente en el Sistema Nacional de Salud español (SNS). Desarrollo y metodología de trabajo: PaSQ se desarrolló a través de 7 paquetes de trabajo, liderados por diferentes países, que estaban orientados prioritariamente a: a) el intercambio de buenas prácticas sobre CA y SP que habían sido identificadas a través de cuestionarios específicos y seleccionadas a través de criterios explícitos consensuados, y b) la implementación de prácticas clínicas seguras (PCS) de comprobada efectividad, acordadas por los Estados Miembros de la Unión Europea. Evolución de la acción cooperativa: Se identificaron 482 buenas prácticas (39% remitidas por profesionales españoles). Se realizaron un total de 34 eventos en la UE, 11 con participación española, que permitieron compartir algunas de estas buenas prácticas. Un total de 194 centros sanitarios (49% españoles) están implementando las 4 PCS acordadas (higiene de manos, cirugía segura, conciliación de la medicación y escala de detección temprana de deterioro clínico en pediatría). Logros alcanzados y perspectivas futuras: PaSQ está facilitando reforzar la colaboración entre organizaciones y profesionales a nivel de la UE y del SNS en torno a la SP y la CA (AU)

Background: The joint action, European Union Network for Patient Safety and Quality of Care: PaSQ, aims to promote patient safety (PS) in the European Union (EU) and to facilitate the exchange of experiences among Member States (MS) and stakeholders on issues related to quality of care, PS, and patient involvement. The development and preliminary results are presented here, especially as regards the Spanish National Health System (SNHS). Development and methodology: PaSQ is developed through 7 work packages, primarily aimed at sharing good practices (GP), which were identified using specific questionnaires and selected by means of explicit criteria, as well as to implement safe clinical practices (SCP) of proven effectiveness and agreed among MS. Evolution of the joint action: A total of 482 GP (39% provided by Spanish professionals) were identified. The 34 events organised in the EU, 11 including Spanish participation, facilitate sharing these practices. A total of 194 Health Care centres (49% in Spain) are implementing SCP (hand hygiene, safe surgery, medication reconciliation, and paediatric early warning scores). Achievements and future perspectives: PaSQ is making it possible to strengthen collaboration between organizations and professionals at EU and SNHS level regarding PS and quality of care (AU)

[European Union Network for Patient Safety and Quality of Care (PASQ). Development and preliminary results in Europe and in the Spanish National Health System]. / Red Europea de Seguridad del Paciente y Calidad (Eupean Network for Patient Safety and Quality of Care). Desarrollo y resultados preliminares en Europa y en el Sistema Nacional de Salud.

BACKGROUND: The joint action, European Union Network for Patient Safety and Quality of Care: PaSQ, aims to promote patient safety (PS) in the European Union (EU) and to facilitate the exchange of experiences among Member States (MS) and stakeholders on issues related to quality of care, PS, and patient involvement. The development and preliminary results are presented here, especially as regards the Spanish National Health System (SNHS). DEVELOPMENT AND METHODOLOGY: PaSQ is developed through 7 work packages, primarily aimed at sharing good practices (GP), which were identified using specific questionnaires and selected by means of explicit criteria, as well as to implement safe clinical practices (SCP) of proven effectiveness and agreed among MS. EVOLUTION OF THE JOINT ACTION: A total of 482 GP (39% provided by Spanish professionals) were identified. The 34 events organised in the EU, 11 including Spanish participation, facilitate sharing these practices. A total of 194 Health Care centres (49% in Spain) are implementing SCP (hand hygiene, safe surgery, medication reconciliation, and paediatric early warning scores) ACHIEVEMENTS AND FUTURE PERSPECTIVES: PaSQ is making it possible to strengthen collaboration between organizations and professionals at EU and SNHS level regarding PS and quality of care.

Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS).

BACKGROUND: Interest in patient safety (PS) is growing exponentially, fuelled by epidemiological research unveiling the extent of unsafe care. However, there is little information about the frequency of harm in developing and transitional countries. To address this issue, the authors performed a study known as the Iberoamerican Adverse Event Study, through a collaborative between the governments of Argentina, Colombia, Costa Rica, Mexico and Peru, the Spanish Ministry of Health, Social Policy and Equality, the Pan American Health Organization and the WHO Patient Safety. METHODS: The study used a cross-sectional design, involving 58 hospitals in the five Latin American countries, to measure the point prevalence of patients presenting an adverse event (AE) on the day of observation. All inpatients at the time of the study were included. RESULTS: A total of 11 379 inpatients were surveyed. Of these, 1191 had at least one AE that the reviewer judged to be related to the care received rather than to the underlying conditions. The estimated point prevalence rate was 10.5% (95% CI 9.91 to 11.04), with more than 28% of AE causing disability and another 6% associated with the death of the patient. Almost 60% of AE were considered preventable. CONCLUSIONS: The high rate of prevalent AE found suggests that PS may represent an important public-health issue in the participating hospitals. While new studies may be needed to confirm these results, these may already be useful to inspire new PS-improvement policies in those settings.

Diseño del estudio IBEAS: prevalencia de efectos adversos en hospitales de Latinoamérica / IBEAS design: adverse events prevalence in Latin American hospitals

Objetivos. Describir las características y metodología del estudio IBEAS: prevalencia de efectos adversos en hospitales de Latinoamérica, que persigue realizar una aproximación a la magnitud, trascendencia e impacto de los eventos adversos (EA); identificar áreas y problemas prioritarios de la seguridad del paciente; incrementar la masa crítica de profesionales involucrados en la seguridad del paciente e incorporar a la agenda de los países objetivos y actividades para mejorar la seguridad del paciente. Método. Estudio sobre la seguridad de los pacientes. Ámbito: 35 hospitales de 5 países: Argentina, Colombia, Costa Rica, México y Perú, a través del análisis de los efectos adversos identificados. Diseño de prevalencia utilizando la revisión de la historia clínica. Resultados. Se describen las implicaciones en el uso del diseño transversal en el estudio de EA, tanto en los recursos necesarios como en la validez interna y en la utilidad para la gestión de riesgos sanitarios. Conclusiones. El diseño transversal es eficiente en tiempo y recursos y fácil de realizar, y aunque no permite estudiar la totalidad del episodio de hospitalización, ha demostrado ser capaz para sostener un sistema de vigilancia. Debido a un posible sesgo de supervivencia, los EA que ocasionen un ingreso se verán sobrerrepresentados, y también aquellos relacionados con la infección nosocomial o los que sean difícilmente identificables si no se ve al paciente. La comunicación con el personal de planta (mientras el paciente está hospitalizado) favorece el juicio de la causalidad del efecto adverso y de su evitabilidad(AU)

Objectives. To describe the methodological characteristics of the IBEAS study: adverse events prevalence in Latin American hospitals, with the aim of analysing the magnitude, significance and impact of adverse events (AE); to identify the main problems associated with patient safety AE; to increase the capacity of professionals involved in patient safety; and the setting up of patient safety agendas in the participating countries. Methods. A patient safety study launched in 35 Latin American hospitals through the analysis of AE in 5 countries: Argentina, Colombia, Costa Rica, Mexico and Peru, using a cross-sectional study using a review of clinical records as the main method. Results. The implications of using a cross-sectional design when studying AE are described, in terms of resources required, internal validity and usefulness related to risk management. Conclusions. The cross-sectional design seems an efficient methodology in terms of time and resources spent, as well as being easy to carry out. Although the cross-sectional design does not review the all hospital episodes, it is able to provide a reliable estimate of prevalence and to support a surveillance system. Because of a possible survival bias, it is likely that the AE which led to hospital admissions will be overestimated, as well as the health related infections or those adverse events which are difficult to identify if the patient is not examined (e.g. contusions). Communication with the ward staff (if the patient is still hospitalised) help in finding the causality and their prevention(AU)

[IBEAS design: adverse events prevalence in Latin American hospitals]. / Diseño del estudio IBEAS: prevalencia de efectos adversos en hospitales de Latinoamérica.

OBJECTIVES: To describe the methodological characteristics of the IBEAS study: adverse events prevalence in Latin American hospitals, with the aim of analysing the magnitude, significance and impact of adverse events (AE); to identify the main problems associated with patient safety AE; to increase the capacity of professionals involved in patient safety; and the setting up of patient safety agendas in the participating countries. METHODS: A patient safety study launched in 35 Latin American hospitals through the analysis of AE in 5 countries: Argentina, Colombia, Costa Rica, Mexico and Peru, using a cross-sectional study using a review of clinical records as the main method. RESULTS: The implications of using a cross-sectional design when studying AE are described, in terms of resources required, internal validity and usefulness related to risk management. CONCLUSIONS: The cross-sectional design seems an efficient methodology in terms of time and resources spent, as well as being easy to carry out. Although the cross-sectional design does not review the all hospital episodes, it is able to provide a reliable estimate of prevalence and to support a surveillance system. Because of a possible survival bias, it is likely that the AE which led to hospital admissions will be overestimated, as well as the health related infections or those adverse events which are difficult to identify if the patient is not examined (e.g. contusions). Communication with the ward staff (if the patient is still hospitalised) help in finding the causality and their prevention.

Prevención de la bacteriemia relacionada con catéteres en UCI mediante una intervención multifactorial. Informe del estudio piloto / Prevention of bacteriema related with ICU catheters by multifactorial intervention: A report of the pilot study

Objetivo: Evaluar la aplicabilidad a nivel nacional de las intervenciones propuestas en el estado de Michigan por Peter Pronovost et al para la prevención de B-CVC en pacientes ingresados en UCI. Diseño: Estudio piloto, prospectivo y comparativo. Ámbito: Han participado 18 UCI (nueve control y nueve intervención) de tres comunidades autónomas de España a lo largo de tres meses en el año 2007. Intervención Incluyó las actividades siguientes: a) programa de formación del personal sanitario; b) introducción de medidas específicas relacionadas con la inserción y manejo de los CVC (lista de comprobación durante la inserción de los CVC, carro exclusivo para accesos venosos, cartel informativo con los cinco procedimientos propuestos para disminuir las bacteriemias: higiene de manos, uso de barreras asépticas máximas durante la inserción, asepsia de la piel del punto de inserción con clorhexidina, evitar la vía de acceso femoral y retirar todos los CVC innecesarios, y c) medidas dirigidas a promover la cultura de seguridad en el trabajo diario (objetivos diarios, aprender de los errores, rondas de seguridad). Resultados: La tasa de B-CVC expresada en medias ha disminuido a la mitad en comparación con los registros históricos. Se identificaron diferentes problemas en la implantación de las medidas específicas relacionadas con los catéteres y en las herramientas de seguridad. Conclusiones: El proyecto de intervención evaluado en el estudio piloto puede ser viable a nivel nacional. Es necesario modificar y adaptar a la realidad española las herramientas propuestas (AU)

Objective: To assess the applicability on a national level of the interventions proposed by Peter Pronovost et al in Michigan state for the prevention of central vascular catheter-related bacteremia (B-CVC) in patients admitted to the ICU. Design: Pilot, prospective and comparative study. Setting: Eighteen ICUs (9 control and 9 intervention) from three autonomous communities in Spain during 3 months in 2007 participated in the study. Intervention: The following activities were included: a) training program for health care personnel, b) introduction of specific measures related to the insertion and care of CVC (catheter insertion checklist, basic recommendations for maintenance of central catheters, dedicated cart for venous accesses, information poster with the five procedures proposed to reduce bacteremias: hands hygiene, use of maximal aseptic barriers during insertion, asepsis of the skin at the insertion point with chlorhexidine, avoidance of the femoral access, and removal of all CVC) and c) measures aiming to promote the culture of safe daily work (daily objectives, learning from mistakes, safety rounds). Results: The rate of B-CVC expressed as mean values has shown a half reduction as compared with historical registers. Different problems in the implementation of specific measures related to catheters and safety tools were identified. Conclusions: The intervention project assessed in the pilot study may be viable on the national level. It is necessary to modify and adapt to the Spanish reality the interventions proposed (AU)

[Prevention of bacteriema related with ICU catheters by multifactorial intervention: a report of the pilot study]. / Prevención de la bacteriemia relacionada con catéteres en UCI mediante una intervención multifactorial. Informe del estudio piloto.

OBJECTIVE: to assess the applicability on a national level of the interventions proposed by Peter Pronovost et al in Michigan state for the prevention of central vascular catheter-related bacteremia (B-CVC) in patients admitted to the ICU. DESIGN: pilot, prospective and comparative study. SETTING: eighteen ICUs (9 control and 9 intervention) from three autonomous communities in Spain during 3 months in 2007 participated in the study. INTERVENTION: the following activities were included: a) training program for health care personnel, b) introduction of specific measures related to the insertion and care of CVC (catheter insertion checklist, basic recommendations for maintenance of central catheters, dedicated cart for venous accesses, information poster with the five procedures proposed to reduce bacteremias: hands hygiene, use of maximal aseptic barriers during insertion, asepsis of the skin at the insertion point with chlorhexidine, avoidance of the femoral access, and removal of all CVC) and c) measures aiming to promote the culture of safe daily work (daily objectives, learning from mistakes, safety rounds). RESULTS: the rate of B-CVC expressed as mean values has shown a half reduction as compared with historical registers. Different problems in the implementation of specific measures related to catheters and safety tools were identified. CONCLUSIONS: the intervention project assessed in the pilot study may be viable on the national level. It is necessary to modify and adapt to the Spanish reality the interventions proposed.