Marfán Luis, Pedemonte Juan C, Sandoval Daniela, Ferdinand Constanza, Camus Lorena, Lacassie Héctor J
División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,
Escuela de Enfermería, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
Rev Med Chil. 2017 Apr;145(4):441-448. doi: 10.4067/S0034-98872017000400004.
Incident reporting is an effective strategy used to enhance patient safety. An incident is an event that could eventually result in harm to a patient.
To classify and analyze incidents reported by an Anesthesiology division at a University hospital in Chile.
A retrospective analysis of the reported incidents registered in our institutional database from January 2008 to January 2014. They were classified according to three variables proposed by the World Health Organization system to determine the type of incident and patients potential harm.
There were 297 reports registered. Etiologic classification according to the WHO system showed that 29% (n = 85) were related with management, 20% (59) with drugs, 20% (59) with medical devices, 16% (48) with procedures and 15% (46) with human factors. Seventy two percent (58) of incidents caused low or moderate harm and 28% (22) resulted in a severe adverse event or death.
Our analysis highlights that a high rate of incidents are associated with management, the leading cause of reports in our center. Due to the low incident report rate in our country, it is difficult to perform appropriate comparisons with other centers. In the future, local incident reporting systems should be improved.
事件报告是用于提高患者安全的一种有效策略。事件是指最终可能对患者造成伤害的事件。
对智利一所大学医院麻醉科报告的事件进行分类和分析。
对2008年1月至2014年1月在我们机构数据库中登记的报告事件进行回顾性分析。根据世界卫生组织系统提出的三个变量对它们进行分类，以确定事件类型和患者的潜在伤害。
共登记了297份报告。根据世界卫生组织系统进行的病因分类显示，29%（n = 85）与管理相关，20%（59）与药物相关，20%（59）与医疗设备相关，16%（48）与操作相关，15%（46）与人为因素相关。72%（58）的事件造成了低或中度伤害，28%（22）导致了严重不良事件或死亡。
我们的分析突出表明，高比例的事件与管理相关，这是我们中心报告的主要原因。由于我国事件报告率较低，很难与其他中心进行适当比较。未来，应改进本地事件报告系统。
