medigraphic.com
SPANISH

Revista Médica del Instituto Mexicano del Seguro Social

  • Contents
  • View Archive
  • Information
    • General Information        
    • Directory
  • Publish
    • Instructions for authors        
  • medigraphic.com
    • Home
    • Journals index            
    • Register / Login
  • Mi perfil

2013, Number 6

<< Back Next >>

Rev Med Inst Mex Seguro Soc 2013; 51 (6)

Adverse events in patients from a pediatric hospital

Ornelas-Aguirre JM, Arriaga-Dávila JJ , Domínguez-Serrano MI, Guzmán-Bihouet BF, Navarrete-Navarro S
Full text How to cite this article

Language: Spanish
References: 36
Page: 680-687
PDF size: 213.91 Kb.


Key words:

patient safety, quality of health care, hospitals pediatric, child.

ABSTRACT

Background: detection of adverse events is part of the safety management in hospitalized patients. The objective of this study was to describe the incidence of adverse events occurred in a pediatric hospital.
Methods: cross-sectional study of the adverse events occurred in a pediatric hospital from 2007 to 2009. Factors associated to their developmental causes were identifi ed. The statistical analysis was descriptive and bivariate, with contingency tables to estimate the relationship between those factors. A p value ≥ 0.05 was considered signifi cant.
Results: a total of 177 adverse events were registered. When they began, human factor occurred in 23 cases (13 %, OR = 1.41, p = 0.001), organizational factor was present in 71 cases (40 %, OR = 1.91, p = 0.236) and technical factor in 46 cases (26 %, OR = 0.87, p = 0.01). Blows or bruises from falls as a result of adverse events occurred in 71 cases (40 %, 95 % CI = 64-78).
Conclusions: we found 1.84 events per 100 hospital discharges during the study period. The fall of patients ranked fi rst of the adverse events identified.


REFERENCES

  1. Alba-Leonel A, Papaqui-Hernández J, Zarza- Arizmendi MD, Fajardo-Ortiz G. Errores de enfermería en la atención hospitalaria. Rev Enferm Inst Mex Seguro Soc. 2011;19(3):149-54. Texto libre en http://www.medigraphic.com/pdfs/enfermeriaimss/ eim2011/eim113g.pdf

  2. Aguirre-Gas HG, Vázquez-Estupiñán F. El error médico. Eventos adversos. Cir Cir. 2006;74(6):495-503. Texto libre en http://www.medigraphic.com/pdfs/ circir/cc-2006/cc066n.pdf

  3. Telles-Tamez ME. Evento centinela en la atención obstétrica: prevención de caídas. Rev Enferm Inst Mex Seguro Soc. 2008;16(1):27-30. Texto libre en http://www.medigraphic.com/pdfs/enfermeriaimss/ eim-2008/eim081f.pdf

  4. Juárez-Pérez H, Durán-Muñoz C. Eventos centinela y la notifi cación por el personal de enfermería. Rev Enferm Inst Mex Seguro Soc. 2009;17(1):39-44. Texto libre en http://www.medigraphic.com/pdfs/ enfermeriaimss/eim-2009/eim091g.pdf

  5. Ruelas-Barajas E, Tena-Tamayo C, Sánchez- González J, Sarabia-González O, Hernández- Gamboa LE, Campos-Castolo EM. Eventos adversos identifi cables en las quejas médicas. Cir Cir. 2008;76(2):153-60.

  6. Rangel-Frausto MS, Valenzuela-Flores A, Navarrete- Navarro S, Tabal-Galán N. Evaluación de los eventos adversos. Una medida para estimar la calidad en los hospitales. En: García-Peña MC, Reyes- Morales H, Viniegra-Velázquez L, editores. Las múltiples facetas de la investigación en salud: proyectos estratégicos del IMSS. Volumen 1. México: IMSS; 2001. p. 311-26.

  7. Ceriani-Cernadas JM. El error en medicina: refl exiones acerca de sus causas y sobre la necesidad de una actitud más crítica en nuestra profesión. Arch Argent Pediatr. 2001;99(6):522-9. Texto libre en http:// www3.sap.org.ar/staticfi les/archivos/2001/arch01 _6/522.pdf

  8. National Coordinating Council for Medication Error Reporting and Prevention. [Sitio web]. What is medication error? [Citado el 9 de agosto de 2010]. Disponible en http://www.nccmerp.org/aboutMed Errors.hmtl

  9. Fernández-Busso N. Los eventos adversos y la calidad de atención. Estrategias para mejorar la seguridad de los pacientes pediátricos. Arch Argent Pediatr. 2004;102(5):402-10. Texto libre en http://www. scielo.org.ar/pdf/aap/v102n5/v102n5a14.pdf

  10. Anaya-Prado R, Pérez-Navarro JV, Medina-Portillo JB, González-Izquierdo JJ, Ayala-López EA. El rol de las organizaciones médicas ante el evento adverso y errores médicos. Cir Gen. 2011;33(Supl 2): S168-72. Texto libre en http://www.medigraphic. com/pdfs/cirgen/cg-2011/cgs112o.pdf

  11. Pierson S, Hansen R, Greene S, Williams C, Akers R, Jonsson M, et al. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. Qual Saf Health Care. 2007;16(4):297-302. Texto libre en http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2464957/pdf/297.pdf

  12. World Health Organization. World Alliance for Patient Safety forward programme 2005. Geneva: World Health Organization; 2004. Texto libre en http://www. who.int/patientsafety/en/brochure_fi nal.pdf

  13. Gaitán-Duarte H, Gómez-Sánchez PI, Eslava-Schmalbach J. Actitudes del personal en la vigilancia de eventos adversos intrahospitalarios en Colombia. Rev Salud Publica. 2009;11(5):745-53. Texto libre en http://www.scielosp.org/pdf/rsap/v11n5/v11n5a07.pdf

  14. Woods D, Thomas E, Holl J, Altman S, Brennan T. Adverse events and preventable adverse events in children. Pediatrics. 2005;115(1):155-60. Texto libre en http://pediatrics.aappublications.org/ content/115/1/155.full.pdf+html

  15. Moguel-Parra G, Amor-Santoyo S, Barragán-Pérez E. Seguridad de los pacientes, prioridad del Hospital Infantil de México: punto de vista del médico como paciente. Bol Med Hosp Infant Mex. 2008;65(5):407- 11. Texto libre en http://www.scielo.org.mx/pdf/bmim/ v65n5/v65n5a10.pdf

  16. 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. Texto libre en http://www.nejm. org/doi/pdf/10.1056/NEJM199102073240604

  17. 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. Texto libre en http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC408508/pdf/20040525s00028p1678.pdf

  18. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust. 1995;163(9):458-71.

  19. Smits M, Zegers M, Groenewegen PP, Timmermans DR, Zwaan L, van der Wal G, et al. Exploring the causes of adverse events in hospitals and potential prevention strategies. Qual Saf Health Care. 2010;19(5):e5. Texto libre en http://qualitysafety.bmj. com/content/19/5/e5.full.pdf+html

  20. Gutiérrez-Vega R. Eventos adversos y seguridad del paciente. An Radiol Mex. 2007;6(3):177.

  21. Viniegra-Velázquez L. La nosología del error médico. Rev Invest Clin. 1998;50(6):505-16.

  22. Cohen H, Robinson ES, Mandrack M. Getting to the root of medication errors: survey results. Nursing. 2003;33(9):36-45.

  23. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess. 2001;(43):i-x, 1-668.

  24. Evans SM, Berry JG, Smith BJ, Esterman A, Selim P, O’Shaughnessy J, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15(1):39-43. Texto libre en http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2563993/pdf/39.pdf

  25. Donoso FA, Fuentes RI. Eventos adversos en UCI. Rev Chil Pediatr. 2004;75(3):233-9. Texto libre en http://www.scielo.cl/scielo.php?pid=S0370-410620 04000300004&script=sci_arttext

  26. Echevarría-Zuno S, Sandoval-Castellanos F, Gutiérrez- Dorantes S, Alcántar-Bautista A, Cote-Estrada L. Eventos adversos en cirugía. Cir Gen. 2011;33(3): 163-9. Texto libre en http://www.medigraphic.com/ pdfs/cirgen/cg-2011/cg113e.pdf

  27. Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745-9. Texto libre en http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC27316/pdf/745.pdf

  28. Wilkins K, Shields M. Correlates of medication error in hospitals. Help Rep. 2008;19(2):1-12. Texto libre en http://www.statcan.gc.ca/pub/82-003-x/ 2008002/ article/10565-eng.pdf

  29. Garbutt J, Brownstein DR, Klein EJ, Waterman A, Krauss MJ, Marcuse EK, et al. Reporting and disclosing medical errors: pediatrician’s attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179- 85. Texto libre en http://archpedi.jamanetwork.com/ article.aspx?articleid=569612

  30. Moreno-Alatorre CR. Evento centinela y error médico en anestesiología. Rev Mex Anestesiol. 2011;34 (4):246-50.

  31. Miller MR, Zhan C. Pediatric patient safety in hospitals: a national picture in 2000. Pediatrics. 2004;113 (6):1741-6.

  32. Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in hospitals in Brazil. Int J Qual Health Care. 2009;21(4):279- 84. Texto libre en http://intqhc.oxfordjournals.org/ content/21/4/279.full.pdf+html

  33. Aranaz JM, Aibar C, Galán A, Limón R, Requena J, Elisa-Álvarez E, et al. Health assistance as a risk factor: side effects related to clinical practice. Gac Sanit. 2006;20(Suppl 1):41-7.

  34. Soop M, Fryksmark U, Köster M, Haglund B. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care. 2009;21(4):285-91.

  35. Meurer JR, Yang H, Guse CE, Scanlon MC, Layde PM; Wisconsin Medical Injury Prevention Program Research Group. Medical injuries among hospitalized children. Qual Saf Health Care. 2006;15(3):202- 7. Texto libre en http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2464854/pdf/202.pdf

  36. Ruiz-López P, Carrasco-González I. Liderazgo en la seguridad del paciente. Rev Calid Asist. 2010;25(2): 55-7.




2020     |     www.medigraphic.com

Mi perfil

C?MO CITAR (Vancouver)

Rev Med Inst Mex Seguro Soc. 2013;51