Adverse clinical events in the hospital: characterization from the point of view of the health worker.

Authors

DOI:

https://doi.org/10.52379/mcs.v6i1.233

Keywords:

Harm to patient, adverse events, patient safety, health personnel.

Abstract

Introduction: an adverse event is an incident that has caused harm to a patient and that may or may not be associated with a clinical error. A high percentage of health professionals are involved in this type of event annually. A large part of the professionals are unaware of the existence of the systems implemented in their work centers for a correct communication of adverse events. Objectives: to identify the characteristics of hospital professionals affected by an adverse event and to evaluate their knowledge of the notification systems. Methods: cross-sectional descriptive observational study. Demographic, labor and related variables with adverse events and notification systems were evaluated. Results: 207, 45.4% nurses and 54.6% doctors, participated, 39.24 ± 10.07 years and with an experience of 14.43 ± 9.9 years. 71.8% were affected by some adverse event. The first adverse event occurred at 6.45 ± 6.18 years. 42.1% knew of some notification system; but only 24.61% of these, affected by an adverse event, reported it. Physicians were more affected by an adverse event, moreover earlier (p <0.001) and they were also more aware of notification systems (p = 0.001). Discussion: many health workers, with little experience, were affected by adverse events. Few knew notification systems and far fewer used them. Doctors were more affected, and earlier, by adverse events and were better acquainted with notification systems.

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References

Rocco C, Garrido A. Seguridad del paciente y cultura de seguridad. Rev. Med. Clin. Condes. 2017; 28(5) 785-795. https://doi.org/10.1016/j.rmclc.2017.08.006

Cuadros K, Grillo K, Toffoletto MC, Henriquez-Roldán C, Canales MA. Ocurrencia de Incidentes de Seguridad del Paciente y Carga de Trabajo de Enfermería. Rev. Latino-Am. Enfermagem 2017;25:e2841. https://doi.org/10.1590/1518-8345.1280.2841

Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Preven-tion. 2021 Aug 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publish-ing; 2021. URL.

Mira JJ, Lorenzo S, Carrillo I, et al. Interventions in health organisations to reduce the impact of adverse events in second and third victims. BMC Health Serv Res. 2015; 341. https://doi.org/10.1186/s12913-015-0994-x

Aranaz JM, Mira JJ, Guilabert M, Herrero JF, Vitaller J, et al. Repercusión de los eventos adversos en los profesionales sanitarios. Estudio sobre las segundas víctimas. Trauma Fund MAPFRE 2013; 24 (1): 54-60. URL.

Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The second victim experience and support tool (SVEST): Validation of an organizational resource for assessing second victim effects and the quality of support resources. J Patient Saf. 2017; 13(2): 93–102. https://doi.org/10.1097/PTS.0000000000000129

Van Gerven E, Bruyneel L, Panella M, Euwema M, Sermeus W, Vanhaecht K. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. BMJ Open 2016;6: e011403. https://doi.org/10.1136/bmjopen-2016-011403

Carrillo I, Ferrús L, Silvestre C, et al. Propuestas para el estudio del fenómeno de las segundas víctimas en España en atención primaria y hospitales. Rev Calid Asist. 2016; 31(S2):3-10. https://doi.org/10.1016/j.cali.2016.04.008

Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726-7. https://doi.org/10.1136/bmj.320.7237.726

Harrison R, Lawton R, Stewart K. Doctors' experiences of adverse events in secondary care: the professional and personal impact. Clin Med 2014; 14: 585–90. https://doi.org/10.7861/clinmedicine.14-6-585

Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open 2016; 6(9): e011708. https://doi.org/10.1136/bmjopen-2016-011708

Waterman AD, Garbutt J, Hazel E et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007; 33:467–76. https://doi.org/10.1016/s1553-7250(07)33050-x

Seys D, Wu AW, Gerven EV, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health ProF. 2013; 36:135–62. https://doi.org/10.1177/016327871245891

Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider ‘‘second victim’’ after adverse patient events. Qual Saf Health Care 2009; 18:325–33. https://doi.org/10.1136/qshc.2009.032870

Saura J, Martínez A, Leal M, Gómez J. Percepción de los residentes de medicina familiar sobre sus errores clínicos tras dos años de formación. SEMERGEN. 2011; 37(6): 280-286 https://doi.org/10.1016/j.semerg.2010.12.013

Treiber LA, Jones JH. Making an infusion error: the second victims of infusion therapy-related medication errors. J Infus Nurs. 2018;41 (3):156–163. https://doi.org/10.1097/NAN.0000000000000273

Cabilan CJ, Kynoch K. Experiences of and support for nurses as second victims of adverse nursing errors: a qualitative systematic review. JBI Database System Rev Implement Rep. 2017;15(9):2333–2364. https://doi.org/10.11124/JBISRIR-2016-003254

O'Connor E, Coates HM, Yardley IE, Wu AW. Disclosure of patient safety incidents: a comprehensive review. Int J Qual Health Care 2010; 22(5): 371-379. https://doi.org/10.1093/intqhc/mzq042

Han K, Bohnen JD, Peponis T et al. The Surgeon as the second victim? Results of the boston intraoperative adverse events surgeons’ attitude (BISA) study. J Am Coll Surg. 2017; 224(6):1048–1056. https://doi.org/10.1016/j.jamcollsurg.2016.12.039

Leape LL, Brennan TA, N Laird et al. 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. https://doi.org/10.1056/NEJM199102073240605

Shor S, Tal O, Maymon R. The second victim: treating the health care providers. Harefuah. 2017;156(1):38–40. URL.

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353: i2139. https://doi.org/10.1136/bmj.i2139

Vanhaecht K, Seys D, Schouten L, et al. Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands. BMJ open 2019; 9(7): e029923. https://doi.org/10.1136/bmjopen-2019-029923

Pyo J, Choi EY, Lee W, et al. Physicians' Difficulties Due to Patient Safety Incidents in Korea: a Cross-Sectional Study. J Korean Med Sci 2020; 35:1-11. https://doi.org/10.3346/jkms.2020.35.e118

Choi EY, Pyo J, Lee W, et al. Nurses’ experiences of patient safety incidents in Korea: a cross-sectional study. BMJ Open 2020; 10:1-11 https://doi.org/10.1136/bmjopen-2020-037741

Published

01/06/2022

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Original Articles

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