Description of the characteristics of the clinical incidents reported in 2020 to the voluntary reporting system of a pediatric hospital in Costa Rica.

Description of the characteristics of the clinical incidents reported in 2020 to the voluntary reporting system of a pediatric hospital in Costa Rica.

Main Article Content

Robinson Rodriguez
Enrique Víctor Mora Enrique
Olga Arguedas Arguedas
Rita Brenes Solano

Abstract

The objective of this manuscript was to describe the clinical incidents that were sent to the voluntary reporting system during 2020 at the National Children's Hospital of Costa Rica, belonging to the Costa Rican Social Security Fund. A descriptive observational study of the consolidated data that was sent during the months of January to December of the year 2020 was carried out. During 2020, 1.6% of the patients treated in the hospital experienced some type of clinical incident. The total discharges decreased by 38.4% compared to the discharges of the year 2019, however, the reported clinical incidents increased in the year 2020 by 37.6%, especially from the month of August. Sentinel events were not reported this year. The services that made the highest number of reports were Intensive Care (14.3%), General Surgery (12%), Neonatology (9.8%) and Infectiology (9%). The day on which the most incidents were reported was Wednesday (27.8%), in the first hospital shift most of the cases were reported (48.1%) and these incidents occurred predominantly to male individuals (66%). Regarding the age of the patients, the majority were in the age range from 1 year to less than 5 years (36.1%), followed by the age range from over 29 days to under 1 year (24, 1%). Most of the cases were related to the care provided to the patient (63.9%). 41.4% of the incidents required clinical measures but the sequelae were transitory. 51.1% of the cases merited some type of additional medical care to their therapeutic scheme upon admission. 96% of clinical incidents were reported by nursing staff. Most of the clinical incidents (35.3%) in this period were errors related to notes in the digital file.

References

Barnes, BA., Brennan, TA., Laird, N., Lawthers, AG., Leape, LL., Localio, AR., et al. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324(6): 377-84.

Banquéd, Marta., Bañeresa, Joaquim., Casasc, Lidia., Navarro, Laura., Orregoa, Carola., Suñola, Rosa. Epidemiología de los eventos adversos hospitalarios en Catalunya: un primer paso para la mejora de la seguridad del paciente. El Servier, Medicina Clínica. https://www.elsevier.es/es-revista-medicina-clinica-2-articulo-epidemiologia-eventos-adversos-hospitalarios-catalunya-S0025775314005508.

Febré, Naldy. Ortega-Lobos, Loreto. Prevalencia de los eventos adversos en centros de hemodiálisis. (2018). Cienc. enferm. [Internet]. 2018 [citado 2021 Feb 04]; 24:7. Disponible en: https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0717-95532018000100207&lng=es. Epub 15-Nov-2018. http://dx.doi.org/10.4067/s0717-95532018000100207.

Organización Mundial de la Salud. Seguridad del paciente. Aspectos sobre la seguridad de los pacientes. https://www.who.int/es/news-room/fact-sheets/detail/patient-safety.

Clinical Safety Research Unit, Imperial College London. Systems Analysis of Clinical Incidents: The London Protocol. (2020) London, United Kingdom.

Organización Mundial de la Salud. Seguridad del Paciente [Internet]. Ginebra: Organización Mundial de la Salud; 2004 oct. 68 p. En: http://www.who.int/patientsafety/es

Organización Mundial de la Salud. Marco Conceptual de la clasificación internacional para la seguridad del paciente. Versión 1.1 [Internet]. Ginebra: Organización Mundial de la Salud; 2009. 160 p. En: http://www.who.int/about/copyright/es/index.html

Rodríguez-Herrera, R.; Losardo, R.J.: Historia de la seguridad del paciente. Hitos principales, desde los albores de la civilización hasta los primeros retos globales y el estudio IBEAS. Revista de la Asociación Médica Argentina; 2018, 131 (4): 25-30.

Organización Mundial de la Salud. Clasificación Internacional para la Seguridad del Paciente (CISP), OMS/OPS, 2006. En: https://www.who.int/patientsafety/implementation/icps/icps_full_report_es.pdf.

Corringan, J.M., Donaldson, M.S., Kahn, L.T. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 199.

Herrera-Castro, Karen V., Gómez-Alpízar, Lorena., Placencia, Francini., Losardo, Ricardo J., Rizzo-Amézquita, José Noé., Rodríguez-Herrera, Robinson., Víctor Mora, Enrique., Yamaguchi-Díaz, Lady Patricia. Incidentes y eventos adversos relacionados con la Seguridad del Paciente. Una propuesta de clasificación. (2019) Boletín CONAMED, México. Volumen 4, No. 22 – 2019.

Bañeresa, Joaquim., Orregoa, Carola., Suñola, Rosa., Ureña, Victoria. Los sistemas de registro y notificación de efectos adversos y de incidentes: una estrategia para aprender de los errores. Revista de Calidad Asistencial, 2005. Vol. 20. Núm. 4. Páginas 216-222. En: https://www.elsevier.es/es-revista-revista-calidad-asistencial-256-articulo-los-sistemas-registro-notificacion-efectos-13075840.

British Medical Journal Editor. Why error reporting systems should be voluntary: they provide better information for reducing errors. BMJ. 2000;320:728-9. Disponible en: http://www.bmj.com/cgi/content/full/320/7237/278.

Estudio IBEAS: prevalencia de Efectos Adversos en hospitales de Latinoamérica. Ministerio de Sanidad y Política Social. 2009. Disponible en: http://www.msc.es/organizacion/sns/planCalidadSNS/docs/INFORME_IBEAS.pdf (https://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/docs/INFORME_IBEAS.pdf)

Flaherty, Panel. Reporting Issues and Learning Approaches. Written Statement. National Summit on Medical Errors and Patient Safety Research. Septiembre 2000. Disponible en: http://www. quic.gov/summit/wflaherty.htm

Rodríguez-Herrera, R., Víctor-Mora, E., Valverde-Gallegos, R. Descripción de la primera curva epidémica por la Covid-19 en Costa Rica. Rev. Ter. 2021;15(1): 96-106

Aronson, Mark., Lawerence D. Callanan., Ship, Amy N., Weingart, Saul N. A physician-based voluntary reporting system for adverse events and medical errors. J.Gen Intern Med 2001: 16:809-814.