It is important to have a clear definition of Adverse events (EA) because there are many variants in the literature.
If there is no damage, it is not Adverse Event.
If the incident or event does not reach the patient, it is not an AE.
An error that is not carried out and does not come into contact with the patient is almost one error or "near miss".
Example: an incorrect preparation of a dilution that is not applied to the patient. This type of incident is also called “close call" in English.
Of all medical procedures, only a fraction become an incident. Official information from the World Health Organization says it is approximately 10%.
These incidents are classified into:
- Avoidable;
- Not Avoidable.
There are medical procedures and medications that have unavoidable consequences or contraindications, they are not Adverse Events, as they are not errors.
Os adverse events They can occur in any sector of the hospital, but they are always related to the patient and must cause harm to be considered.
AEs must be reported to the system responsible for Patient safety.
The percentage of AEs reported varies from country to country, depending on the hospital culture. Where there is a culture of blame, many reports are ignored. Typically only 10% of real AEs are reported.
There are systems to automatically calculate the level of EA such as Global Trigger Tool da IHI (Institute for Health Improvement) which is independent of complaints and can increase the AEs to be considered by up to 10 times.
Only 2 to 3% of AEs are the responsibility of the healthcare professional, almost entirely being system problems.
There are many hospitals that are committed to not blaming doctors and healthcare professionals in order to get more self-reporting and improve quality.
Following the trail of near-misses is an intelligent procedure for studying how to improve processes, without getting into the subject of culture, because as there was no error, there is no one to blame.
There are errors of commission (by doing) and errors of omission (by not doing). Both types are included in studies of Adverse events.
Although human intervention is necessary to commit an error, systemic failure is the main culprit in more than 95% of cases.
Stress, work overload and long hours are the main cause of distractions and carelessness, working in automatic or subconscious mode that causes errors.
Only a small proportion of AEs are caused by serious negligence, that is, by people who systematically violate procedural rules and who are the only ones who should be blamed.
While we cannot change the human condition, we can change the conditions under which human beings work.
