2011, Number 3
<< Back Next >>
Cir Gen 2011; 33 (3)
Adverse events in surgery
Echevarría ZS, Sandoval CF, Gutiérrez DS, Alcantar BA, Cote EL
Language: Spanish
References: 15
Page: 163-169
PDF size: 103.56 Kb.
ABSTRACT
Objective: To analyze the adverse events reported to the Notification System of sentinel event, adverse event, and quasi-failure “VENCER II” of the Mexican Institute of Social Security (IMSS, for its initials in Spanish).
Setting: Medical Care Unit, IMSS
Design: Cross-sectional, retrospective, observational, descriptive study.
Statistical analysis: Percentages as summary measure for qualitative variables.
Material and methods: We present a review of the adverse events reported in one month. In this investigation, we included two types of events: those related to surgical procedures and those to infectious processes.
Results: Total of adverse events, 78, the most affected age group was that of 16 to 45 years (49%), the predominating gender was the female with 66%; the shift during which they occurred most frequently was the morning shift with 77%, the specialty with the highest incidence was general surgery with 51%. In regard to origin, infections of the surgical site corresponded to 69%, other nosocomial infections represented 1.5%, and non-infectious cases corresponded to 29.5% (organ lesion); severity was moderate in 71%, and the medical personnel was the most infrequently involved with 57%.
Conclusion: The system provides permanent feedback, as well as an analysis to identify the root cause and the improvement actions to reduce and prevent adverse events.
REFERENCES
Aranaz JM, Aibar C, Gea MT, León MT. Los efectos adversos en la asistencia hospitalaria. Una revisión crítica. Med Clín (Barc) 2004; 123: 21-25.
Secretaría Nacional de Sanidad Estudio Nacional de los Efectos Adversos ligados a la Hospitalización. ENEAS 2005. http://www.errorenmedicina.anm .edu.ar/pdf/recursos /documentos/43_Estudio_ENEAS.
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995; 274: 29-34.
Gutiérrez VR. La Calidad de la atención médica y la seguridad del paciente quirúrgico. Rev CONAMED 2011; 16: 51-52.
(http://www.hunter.health.nsw.gov.au/clinicalgovernance/aims.htm) julio 2011
Bañeres J, Orrego C, Suñol R, Ureña V. Los sistemas de registro y notificación de efectos adversos y de incidentes: una estrategia para aprender de los errores. Rev Calidad Asistencial 2005; 20: 216-222.
http://dgdi-conamed.salud.gob.mx/sirais/ 10 de septiembre 2011.
Grande L. Mejorar la seguridad en el quirófano, reduce la mortalidad hospitalaria. Cir Esp 2009; 86: 329-330.
Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999; 126: 66-75.
Sistema de Estadística Institucional CONAMED http://www.conamed.gob.mx/main_2010. 10 septiembre 2011
del Valle-García M. Creación de un Sistema de Notificación y Registro de Incidentes y Eventos Adversos en la esfera sanitaria desde un punto de vista jurídico. Rev Cient Soc Esp Enferm Neurol 2010; 32: 42-43.
Aguiló J, Peiró S, Muñoz C, García CJ, Garay M, Viciano V, et al. Efectos adversos en la cirugía de la apendicitis aguda. Cir Esp 2005; 78: 312-7.
Ponce de León S, Rangel-Frausto MS, Elias-López JI, Romero Oliveros C, Huertas Jiménez M. Las infecciones nosocomiales: tendencias seculares de un programa de control en México. Salud Pública Mex 1999; 41: S5-11.
Zegers M, de Bruijne MC, de Keizer B, Marten H, Groenewegen PP, van de Wal G, et al. The Incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies. Patient Saf Surg 2011; 5: 13.
García-Armesto S, Kelley E, Klazinga N, Wei L. Claves y retos en la comparación internacional de la seguridad del paciente: la experiencia del Health Care Quality Indicators Project de la OCDE. Rev Calidad Asistencial 2007; 22: 327-334.
Full text