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

Article information

Resumen

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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Bibliografía

[1.]

D. Barr.

Hazards of modern diagnosis and therapy: the price we pay.

JAMA, 159 (1955), pp. 1452-1456

[2.]

R. Moser.

Diseases of medical progress.

N Engl J Med, 255 (1956), pp. 606-614

http://dx.doi.org/10.1056/NEJM195609272551306 | Medline

[3.]

E.M. Schimel.

The hazards of hospitalization.

Qual. Saf. Health Care, 12 (2003), pp. 58-63

Medline

[4.]

Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.

[5.]

WHO. Website de la Alianza Mundial por la Seguridad del Paciente [citado 21 Dic 2007]. Disponible en: http://www.who.int/patientsafety/en/

[6.]

J.M. Aranaz, C. Aibar, M.T. Gea, M.T. León.

Los efectos adversos en la asistencia hospitalaria. Una revisión crítica.

Med Clin (Barc), 123 (2004), pp. 21-25

[7.]

T.A. Brennan, L.L. Leape, N.M. Laird, L. Hebert, A.R. Localio, A.G. Lawthers, et al.

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

N Engl J Med, 324 (1991), pp. 370-377

http://dx.doi.org/10.1056/NEJM199102073240604 | Medline

[8.]

E.J. Thomas, D.M. Studdert, H.R. Burstin, E.J. Orav, T. Zeena, E.J. Williams, et al.

Incidence and types of adverse events and negligent care in Utah and Colorado.

Med Care, 38 (2000), pp. 261-271

Medline

[9.]

R.M. Wilson, W.B. Runciman, R.W. Gibberd, B.T. Harrison, L. Newby, J.D. Hamilton.

The Quality in Australian Health Care Study.

Med J Aust, 163 (1995), pp. 458-471

Medline

[10.]

C. Vincent, G. Neale, M. Woloshynowych.

Adverse events in British hospitals: preliminary retrospective record review [published erratum in BMJ 2001;322:1395].

BMJ, 322 (2001), pp. 517-519

Medline

[11.]

T. Schioler, H. Lipczak, B.L. Pedersen, et al.

Incidence of adverse events in hospitals. A retrospective study of medical records.

Ugeskr Laeger, 163 (2001), pp. 5370-5378

Medline

[12.]

P. Davis, R. Lay-Yee, R. Briant, W. Ali, A. Scott, S. Schug.

Adverse events in New Zealand public hospitals (I): ocurrence and impact.

N Z Med J, 115 (2002), pp. 271U

Article

[13.]

G.R. Baker, P.G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox, et al.

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

JAMA, 170 (2004), pp. 1678-1686

[14.]

P. Michel, J.L. Quenon, A. Djihoud, S. Tricaud-Vialle, A.M. de Sarasqueta.

French national survey of inpatient adverse events prospectively assessed with ward staff.

Qual Saf Health Care, 16 (2007), pp. 369-377

http://dx.doi.org/10.1136/qshc.2005.016964 | Medline

[15.]

Aranaz JM, Aibar C, Vitaller J, Ruiz P. Estudio Nacional sobre los Efectos Adversos ligados a la Hospitalización. ENEAS 2005. Madrid: Ministerio de Sanidad y Consumo; 2006. Depósito legal: M. 19200-2006 [citado 21 Dic 2007]. Disponible en: http://www.msc.es/organizacion/sns/planCalidadSNS/docs/eneas2005Baja.pdf

[16.]

M. Zegers, M.C. De Bruijne, C. Wagner, P.P. Groenwegen, R. Waaijman, G. Van der Wal.

Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals.

BMC Health Serv Res, 7 (2007), pp. 27

http://dx.doi.org/10.1186/1472-6963-7-27 | Medline

[17.]

E.J. Moskowitz, D.B. Nash.

The quality and safety of ambulatory medical care: current and future prospects.

Am J Med Qual, 22 (2007), pp. 274-288

http://dx.doi.org/10.1177/1062860607303255 | Medline

[18.]

D.M. Woods, E.J. Thomas, J.L. Holl, K.B. Weiss, T.A. Brennan.

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

Qual Saf Health Care, 16 (2007), pp. 127-131

http://dx.doi.org/10.1136/qshc.2006.021147 | Medline

[19.]

Agency for Healthcare Research and Quality. Website de Seguridad del Paciente de la AHRQ [citado 21 Dic 2007]. Disponible en: http://www.ahrq.gov/qual/errorsix.htm

[20.]

National Quality Forum. Website de estándares de cuidados del NQF [citado 21 Dic 2007]. Disponible en: http://www.qua-lityforum.org/projects/completed/safe_practices/

[21.]

National Patient Safety Agency. Website de herramientas para el estudio de los efectos adversos [citado 21 Dic 2007]. Disponible en: http://www.npsa.nhs.uk/patientsafety/improving-patientsafety

[22.]

Joint Commissión International Center for Patient Safety. Website de soluciones para la seguridad del paciente [citado 21 Dic 2007]. Disponible en: http://www.jcipatientsafety.org/

[23.]

Agencia de Calidad del Sistema Nacional de Salud. Website sobre seguridad del paciente [citado 21 Dic 2007]. Disponible en: http://www.seguridaddelpaciente.es/

[24.]

WHO. Website del segundo reto mundial por la seguridad del paciente [citado 21 Dic 2007]. Disponible en: http://www.who.int/patientsafety/challenge/safe.surgery/en/index.html

[25.]

P. Davis, R. Lay-Yee, R. Briant, W. Ali, A. Scott, S. Schug.

Adverse Events in New Zealand public hospitals (II): preventability and clinical context.

N Z Med J, 116 (2003), pp. 624U

[26.]

R.K. Resar, J.D. Rozich, T. Simmonds, C.R. Haraden.

A trigger tool to identify adverse events in the intensive care unit.

Jt Cimm J Qual Patient Saf, 32 (2006), pp. 585-590

[27.]

M. Healey, S. Shackford, T. Osler, F. Rogers, E. Burns.

Complications in surgical patients.

Arch Surg, 137 (2002), pp. 611-618

Medline

[28.]

D. Woods, E. Thomas, J. Holl, S. Altman, T. Brennan.

Adverse events and preventable adverse events in children.

Pediatrics, 115 (2005), pp. 155-160

http://dx.doi.org/10.1542/peds.2004-0410 | Medline

[29.]

A.C. O’Neil, L.A. Petersen, E.F. Cook, D.W. Bates, T.H. Lee, T.A. Brennan.

Physician reporting compared with medical-record review to identify adverse medical events.

Ann Intern Med, 119 (1993), pp. 370-376

Medline

[30.]

A. Forster, N. Rose, C. Van Walraven, I. Stiell.

Adverse events in the emergency department.

Qual Saf Health Care, 16 (2007), pp. 17-22

http://dx.doi.org/10.1136/qshc.2005.017384 | Medline

[31.]

A.W. Wu, P. Pronovost, L. Morlock.

ICU incident reporting systems.

J Crit Care, 17 (2002), pp. 86-94

Medline

[32.]

A.L. Samperiz, M.T. Rubio, F. Escolar, J.L. Alonso, A. Lanas, T. Ayuso.

Estudio de la patología yatrógena en un servicio de Medicina Interna.

Rev Clin Esp, 194 (1994), pp. 457-463

Medline

[33.]

E.J. Thomas, T.A. Brennan.

Incidence and types of preventable adverse events in eldrely patients: population based review of medical records.

BMJ, 320 (2000), pp. 740-744

[34.]

A.A. Gawande, E.J. Thomas, M.J. Zinner, T.A. Brennan.

The incidence and nature of surgical adverse events in Colorado and Utah in 1992.

Surgery, 126 (1999), pp. 66-75

http://dx.doi.org/10.1067/msy.1999.98664Article | Medline

[35.]

Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, Sarasqueta AM, Domecq S. Les évenements indésirables graves liés aux soins observés dans les établiments de santé: premiers résultats d’une étude nationale. Paris: DRESS; 2005. Études et résultats. N.° 398.

[36.]

III Conferencia Internacional en Seguridad de Pacientes: los pacientes por la seguridad del paciente. Ministerio de Sanidad y Consumo [citado 21 Dic 2007]. Disponible en: http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/excelen-cia/eventos/seguridaddelpaciente.html

[37.]

T.A. Brennan, A.R. Localio, N.M. Laird.

Reliability and validity of judgements concerning adverse events suffered by hospitalized patients.

Med Care, 12 (1989), pp. 1148-1158

[38.]

A.R. Localio, S.L. Weaver, J.R. Landis, A.G. Lawthers, T.A. Brennan, L. Hebert, et al.

Identifying adverse events caused by medical care: degree of physician agreement in a restrospective chart review.

Ann Intern Med, 125 (1996), pp. 457-464

Medline

[39.]

K. Walshe.

Adverse events in health care: issues in measurement.

Qual Health Care, 9 (2000), pp. 47-52

Medline

[40.]

E.J. Thomas, D.M. Studdert, T.A. Brennan.

The reliability of medical record review for estimating adverse event rates.

Ann Intern Med, 136 (2002), pp. 812-816

Medline

[41.]

Plan de calidad para el Sistema Nacional de Salud. Altas atendidas en los hospitales generales del SNS. Año 2005. Ministerio de Sanidad y Consumo [citado 21 Dic 2007]. Disponible en: http://www.msc.es/estadEstudios/estadisticas/cmbd.htm

[42.]

J.M. Rothschild, D.W. Bates, L.L. Leape.

Preventable medical injuries in older patients.

Arch Intern Med, 160 (2000), pp. 2717-2728

Medline

[43.]

C. Aibar, J.M. Aranaz.

Seguridad del Paciente y prevención de efectos adversos relacionados con la asistencia [CD ROM].

Ministerio de Sanidad y Consumo, (2007),

[44.]

P. Ruiz, C. González, J. Alcalde.

Análisis de causas raíz. Una herramienta útil para la prevención de errores.