Operational performance, concordance and coincidence between passive and active safety event reporting systems in the surgery service in a teaching hospital in Colombia

  • Kelly Estrada-Orozco a. Clinical Research Institute, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia. b. Center for Evidence to Implementation, Bogotá, Colombia.
  • Steffany L. Villate-Soto Public Health Area, Instituto Nacional de Cancerología, Bogotá, Colombia.
  • Hernando Gaitán-Duarte Clinical Research Institute, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
Keywords: Patient safety, Medical error, Adverse event, Notification, Risk management

Abstract

Introduction: Reporting systems (RSs) are the rst step to improve patient safety in health institutions, consequently determining their performance is relevant.

Objective: To determine the performance in terms of positive predictive value (PPV), the concordance, and the coincidence of passive and active RSs in the detection of true clinical incidents and reportable events with unwanted effects (REUWEs), in a teaching hospital in Bogotá, Colombia.

Methods: Cross-sectional study, assembled in a retrospective cohort, consistingofhospitalizedpatients (>12hours) in thesurgery service, between May and July 2017. The PPV was calculated for the detection of patients with clinical incidents or REUWE in both RS. Concordance and coincidence between RS were determined.

Results: The incidence of REUWE from the passive RS was lower than the incidence from the active RS (2% vs 11.8%), the PPV for the identication of patients with clinical incidents and REUWE was similar (PPV patients with clinical incidents: passive 95% condence interval [CI] 34.6–66.2 vs active 95% CI 45.1–71.7; and PPV patients with REUWE: passive 95% CI 36.8–65.4 vs active 95% CI 29.3–54.9). Concordance was acceptable (Kappa 0.38) and the coincidence of patients and their REUWEs was 15.38%.

Conclusion: In the active and passive RSs, the detection of true clinical incidents and REUWE (PPV) was similar and the concordance in the detection of subjects with REUWE was acceptable. However, the coincidence between the REUWEs in the patients detected by each RS was substantially different and should be considered when analyzing the information coming from one or another RS.

References

Ministerio de Salud y Protección Social. Lineamientos para la implementación de políticas en seguridad del paciente. Bogotá: MSPS; 2008.

Estrada-Orozco K, Gaitán-Duarte H, Moreno S, Moreno-Chaparro J. Reportable hospital events: incidence and contributing factors in the surgery service of a high complexity hospital in Bogotá, Colombia, 2017. Colombian Journal of Anesthesiology. 2019;47:5-13. DOI: http://doi.org/10.1097/CJ9.0000000000000091

Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, et al. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. BMJ (Clinical research ed). 2000;320(7237):777-81. DOI: http://doi.org/10.1136/bmj.320.7237.777

Bañeres JCE, López L, Orrego C, Suñol R. Sistemas de registro y notificación de incidentes y eventos adversos. Minist Sanid y Consum [Internet]. 2006 [citado feb. 23 2020]. Disponible en: https://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/pdf/excelencia/opsc_sp3.pdf

Sarabia González OP-VO, Vera WT, Latorre FG. Análisis comparativo hospitalario del evento adverso en México: Utilidad del reporte voluntario en línea. Rev Calid Asist. 2007;22(6):342-8. ID: ibc-65517

Ferranti J, Horvath MM, Cozart H, Whitehurst J, Eckstrand J. Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics. 2008;121(5):e1201-7. DOI: http://doi.org/10.1542/peds.2007-2609

Pohlman KA, Carroll L, Tsuyuki RT, Hartling L, Vohra S. Active versus passive adverse event reporting after pediatric chiropractic manual therapy: study protocol for a cluster randomized controlled trial. Trials. 2017;18(1):575. DOI: http://doi.org/10.1186/s13063-017-2301-0

Institute of Medicine IOM. Committee on Quality of Health Care in America. En: Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: Building a safer health system. Washington: National Academies Press; 2000.

Ministerio de la Protección Social. Seguridad del paciente y atención en salud. Paquetes instruccionales. Guía técnica “buenas prácticas para la seguridad del paciente y la atención en salud”. Bogotá, Colombia: Ministerio de Salud y la Protección Social; 2010.

Pohlman KA, Carroll L, Hartling L, Tsuyuki RT, Vohra S. Barriers to implementing a reporting and learning patient safety system: Pediatric chiropractic perspective. J Evid Based Complementary Altern Med. 2016;21(2):105-9. DOI: http://doi.org/10.1177/2156587215609191

Chrysant SG. Proactive compared with passive adverse event recognition: calcium channel blocker-associated edema. J Clin Hypertens (Greenwich). 2008;10(9):716-22. DOI: http://doi.org/10.1111/j.1751-7176.2008.00006.x

Gaitán-Duarte H, Eslava-Schmalbach J, Rodríguez-Malagón N, Forero-Supelano V, Santofimio-Sierra D, Altahona H. Incidencia y evitabilidad de eventos adversos en pacientes hospitalizados en tres instituciones hospitalarias en Colombia, 2006. Revista de Salud Pública. 2008;10:215-26.

Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-86. DOI: http://doi.org/10.1503/cmaj.1040498

Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-6. DOI: http://doi.org/10.1056/NEJM199102073240604

Ministerio de Salud y protección Social. Seguridad del paciente [internet]. 2010 (Última actualización 24 de febrero de 2020) [citado febrero 24. 2020]. Disponible en: https://www.minsalud.gov.co/salud/CAS/Paginas/seguridad-del-paciente.aspx

Asociación Médica Mundial. Declaración de Helsinki de la AMM. Principios éticos para las investigaciones médicas en seres humanos. Asoc Medica Mund [Internet] 2013. [citado febrero 24. 2020]. Disponible en: http://www.redsamid.net/archivos/201606/2013-declaracion-helsinki-brasil.pdf?1

Ministerio de salud y la protección Social. Resolución número 8430 de 1993. Por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. Colombia (2007).

Castañeda-Hidalgo HGHR, Zúñiga MP, Porras GA, Pérez AA. Percepción de la cultura de la seguridad de los pacientes por personal de enfermería. Cienc y Enferm. 2013;2:77-88. DOI: http://doi.org/10.4067/S0717-95532013000200008

Hamashima C. Benefits and harms of endoscopic screening for gastric cancer. World J Gastroenterol. 2016;22(28):6385-92. DOI: http://doi.org/10.3748/wjg.v22.i28.6385

Duckers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90s-119s. DOI: http://doi.org/10.1177/1077558709345870

Burbano Valdés HM, Caicedo Eraso ME, Cerón Burgos A, Jacho Caicedo C, Yépez Chamorro MC. Causas del no reporte de eventos adversos en una institución prestadora de servicios de salud en Pasto - Nariño, Colombia. Universidad y Salud. 2013;15:187-95.

Daverio M, Fino G, Luca B, Zaggia C, Pettenazzo A, Parpaiola A, et al. Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children. Paediatr Anaesth. 2015;25(12):1227-34. DOI: http://doi.org/10.1111/pan.12772.

Parada DBL, Ballesteros N, Rodríguez J, Guampe L, Vanessa C. Frecuencia, evitabilidad y consecuencias de los eventos adversos. Cienc y Cuid. 2011;8(1):75-83.

Jha AK, Kuperman GJ, Teich JM, Leape L, Shea B, Rittenberg E, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. JAMIA. 1998;5(3):305-14. DOI: http://doi.org/10.1136/jamia.1998.0050305

Sorra JGL, Streagle S, et al. AHRQ Hospital Survey on Patient Safety Culture: User’s Guide [Internet]. AHRQ Publication. 2016 [citado Noviembre 20. 2019]. Disponible en: http://www.ahrq.gov/professionals/quality-patientsafety/patientsafetyculture/hospital/index.html.

How to Cite
1.
Estrada-Orozco K, Villate-Soto SL, Gaitán-Duarte H. Operational performance, concordance and coincidence between passive and active safety event reporting systems in the surgery service in a teaching hospital in Colombia. Colomb. J. Anesthesiol. [Internet]. 2020 Sep. 7 [cited 2024 Mar. 28];48(4). Available from: https://www.revcolanest.com.co/index.php/rca/article/view/923

Downloads

Download data is not yet available.
Published
2020-09-07
How to Cite
1.
Estrada-Orozco K, Villate-Soto SL, Gaitán-Duarte H. Operational performance, concordance and coincidence between passive and active safety event reporting systems in the surgery service in a teaching hospital in Colombia. Colomb. J. Anesthesiol. [Internet]. 2020 Sep. 7 [cited 2024 Mar. 28];48(4). Available from: https://www.revcolanest.com.co/index.php/rca/article/view/923
Section
Original

Altmetric

Article metrics
Abstract views
Galley vies
PDF Views
HTML views
Other views
QR Code

Some similar items: