Esqué Ruiz M T, Moretones Suñol M G, Rodríguez Miguélez J M, Parés Tercero S, Cortés Albuixech R, Varón Ramírez E M, Figueras Aloy J
Departamento de Neonatología, Institut Clínic Ginecologia Obstetrícia i Neonatologia, Hospital Clínic sede Maternitat, Barcelona, España.
Departamento de Neonatología, Institut Clínic Ginecologia Obstetrícia i Neonatologia, Hospital Clínic sede Maternitat, Barcelona, España.
An Pediatr (Barc). 2015 Oct;83(4):236-43. doi: 10.1016/j.anpedi.2014.12.012. Epub 2015 Jan 29.
A safety culture is the collective effort of an institution to direct its resources toward the goal of safety.
An analysis is performed on the six years of experience of the Committee on the Safety of Neonatal Patient. A mailbox was created for the declaration of adverse events, and measures for their correction were devised, such as case studies, continuous education, prevention of nosocomial infections, as well as information on the work done and its assessment.
A total of 1287 reports of adverse events were received during the six years, of which 600 (50.8%) occurred in the neonatal ICU, with 15 (1.2%) contributing to death, and 1282 (99.6%) considered preventable. Simple corrective measures (notification, security alerts, etc.) were applied in 559 (43.4%), intermediate measures (protocols, monthly newsletter, etc.) in 692 (53.8%), and more complex measures (causal analysis, scripts, continuous education seminars, prospective studies, etc.) in 66 (5.1%). As regards nosocomial infections, the prevention strategies implemented (hand washing, insertion and maintenance of catheters) directly affected their improvement. Two surveys were conducted to determine the level of satisfaction with the Committee on the Safety of Neonatal Patient. A rating 7.5/10 was obtained in the local survey, while using the Spanish version of the Hospital Survey on Patient Safety Culture the rate was 7.26/10.
A path to a culture of safety has been successfully started and carried out. Reporting the adverse events is the key to obtaining information on their nature, etiology and evolution, and to undertake possible prevention strategies.
安全文化是一个机构为实现安全目标而集中资源做出的共同努力。
对新生儿患者安全委员会六年的经验进行分析。设立了一个用于报告不良事件的邮箱,并制定了针对这些事件的纠正措施,如案例研究、持续教育、医院感染预防,以及关于所做工作及其评估的信息。
六年期间共收到1287份不良事件报告,其中600例(50.8%)发生在新生儿重症监护病房,15例(1.2%)导致死亡,1282例(99.6%)被认为是可预防的。559例(43.4%)采取了简单的纠正措施(通知、安全警报等),692例(53.8%)采取了中等措施(方案、月度通讯等),66例(5.1%)采取了更复杂的措施(因果分析、脚本、持续教育研讨会、前瞻性研究等)。关于医院感染,实施的预防策略(洗手、导管插入和维护)直接影响了感染情况的改善。进行了两项调查以确定对新生儿患者安全委员会的满意度。在本地调查中获得了7.5/10的评分,而使用西班牙语版的医院患者安全文化调查时评分是7.26/10。
已成功开启并实施了通往安全文化的道路。报告不良事件是获取有关其性质、病因和演变信息以及采取可能预防策略的关键。