Macías Maroto M, Garzón González G, Navarro Royo C, Navea Martín A, Díaz Redondo A, Santiago Saez A, Pardo Hernández A
Unidad de Calidad, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
Área de Procesos y Calidad, Gerencia Asistencial de Atención Primaria, SERMAS, Consejería de Sanidad, Madrid, España.
J Healthc Qual Res. 2022 Nov-Dec;37(6):397-407. doi: 10.1016/j.jhqr.2022.03.003. Epub 2022 May 30.
To determine the impact of the COVID-19 pandemic on the epidemiology of safety incidents (SI) and medication errors (ME) reported to the CISEMadrid notification system in the hospital and primary care settings of the Madrid Health Service (SERMAS).
Observational and descriptive study with a retrospective analysis of data including all CISEMadrid notifications from 01-Jan-2018 to 31-Dec-2020, from 33 hospitals and 262 health care centres of the SERMAS. The two periods in 2020 with the greatest increase in COVID-19 cases were identified to compare incidents reported in the pre-pandemic and pandemic periods.
36,494 incidents were reported. Comparing both periods, an overall decrease in pandemic notifications of 60.7% was observed, being higher in primary care, falling to 33% of previous levels. The reduction in notifications was similar in the peaks and valleys of the waves. The three most frequent SIs in both periods and care settings were: diagnostic tests, medical devices/equipment/clinical furniture and organisational management/citations. In ME, dose failure and inappropriate selection were the most frequent in both settings and periods. There were no relevant differences in patient consequences in both periods.
During the pandemic, patient safety notifications decreased although the most frequent types remained the same, as did their impact on the patient, both in hospitals and in primary care. The safety culture of organisations is a critical aspect for the maintenance of reporting systems.
确定新型冠状病毒肺炎(COVID-19)大流行对马德里卫生服务局(SERMAS)医院及初级保健机构中向CISEMadrid通报系统报告的安全事件(SI)及用药错误(ME)流行病学的影响。
采用观察性和描述性研究,对2018年1月1日至2020年12月31日期间SERMAS的33家医院和262个医疗保健中心的所有CISEMadrid通报数据进行回顾性分析。确定2020年COVID-19病例增加最多的两个时期,以比较大流行前和大流行期间报告的事件。
共报告了36494起事件。比较两个时期,发现大流行期间通报的事件总体减少了60.7%,在初级保健机构中降幅更大,降至之前水平的33%。通报的减少在疫情波峰和波谷时相似。两个时期及不同医疗环境中最常见的三类安全事件分别为:诊断检查、医疗设备/器械/临床家具以及组织管理/传唤。在用药错误方面,剂量错误和选择不当在两个医疗环境及两个时期中最为常见。两个时期在患者后果方面无显著差异。
在大流行期间,患者安全通报减少,尽管最常见的类型保持不变,且无论是在医院还是初级保健机构中,其对患者的影响也相同。组织的安全文化是维持报告系统的关键因素。