Luces y sombras en la seguridad del paciente: estudio y desarrollo de estrategias. Informe SESPAS 2008

Aranaz-Andrés, Jesús M.; Limón-Ramírez, Ramón; Aibar-Remón, Carlos; Miralles-Bueno, Juan José; Vitaller-Burillo, Julián; Terol-García, Enrique; Gea-Velázquez de Castro, M. Teresa; Requena-Puche, Juana; Rey-Talens, Milagros

doi:10.1016/S0213-9111(08)76093-X

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El estudio sobre la frecuencia de los efectos adversos (EA) ligados a la asistencia, su efecto en los pacientes y el impacto en los sistemas de salud ha experimentado un intenso impulso en los últimos años. El análisis individual profundo de sus factores contribuyentes ha permitido el desarrollo de múltiples estrategias para prevenirlos o minimizar su impacto, pero es necesaria una perspectiva epidemiológica para explorar estas posibles asociaciones y generalizar las recomendaciones que se deriven de este análisis.

Se comentan algunos de los aspectos que se deberían tener en cuenta para el desarrollo de estrategias futuras, como la importancia de la edad o las comorbilidades del paciente en la génesis de los EA y el alto grado de la instrumentalización de la asistencia (a veces innecesaria). Son imprescindibles una cultura de confianza y confidencialidad y un espíritu de colaboración entre las organizaciones para poder compartir y aprender de las iniciativas derivadas del estudio de los EA, y así mejorar la seguridad de los pacientes en el Sistema Nacional de Salud.

Palabras clave:

Seguridad clínica

Efectos adversos

Errores médicos

Abstract

Study of the frequency of healthcare-related adverse events (AE) and of their effect on patients and impact on healthcare systems has markedly increased in recent years. Indepth individual analysis of the factors contributing to these events has allowed strategies to prevent or minimize the impact of AE to be developed. However, an epidemiologic perspective is needed to explore possible associations and generalize the recommendations that can be drawn from this type of analysis.

Some aspects that should been considered while developing future strategies are discussed. These aspects include the importance of patient age and comorbidities on producing AE and the use of highly technological medicine, which is sometimes unnecessary. A culture of trust and confidentiality and a spirit of collaboration among organizations are indispensable to share and learn about the initiatives prompted by the study of AE and thereby improve patient safety in the national health service.

Key words:

Patient safety

Adverse events

Medical errors

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