Descripción de factores contribuyentes en sucesos adversos relacionados con la seguridad del paciente y su evitabilidad

OBJECTIVE: To assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. DESIGN: Retrospective descriptive study. LOCATION: Porriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. PARTICIPANTS AND/OR CONTEXT: Reported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP). METHOD: The variables measured were: Near Incident (NI) an occurrence with no effect or harm on the patient; Adverse Event (AE) an occurrence that affects or harms a patient. The level of harm is classified as minimal, minor, moderate, critical, and catastrophic. Preventability was classified as little evidence of being preventable, 50% preventable, and sound evidence of being preventable. Data analysis: percentages and Chi-squared test for qualitative variables; P < .05 with SPSS.15. Data source: SiNASP. Ethical considerations: approved by the Research Ethics Committee (2016/344). RESULTS: There were 166 recorded AEs (50.6% in males, and 46.4% in women. The mean age was 60.80 years). Almost two-thirds 62.7% of AEs affected the patient, with 45.8% causing minimal damage, while 2.4% caused critical damages. Healthcare professionals were a contributing factor in 71.7% of the AEs, with the trend showing that poor communication and lack of protocols were related to the damage caused. Degree of preventability: 96.4%. CONCLUSIONS: Most AEs affected the patient, and were related to medication, diagnostic tests, and laboratory errors. The level of harm was related to communication problems, lack of, or deficient, protocols and a poor safety culture.