An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification

Abstract

More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach; 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to “get it right” by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.

Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System

“…Nonetheless, potentially just one in five incidents are reported [41]. Aside from this, data are subject to classification and hindsight bias [42,43], with a fundamental difficulty in assigning a single classification to what is often a cascade of errors [44], all compounded by the lack of a universal taxonomy and analysis framework [45]. Medication or treatment failure may be difficult to distinguish, particularly in anaesthetics, and the hierarchy in the taxonomy may confuse or hide incidents, with for example, an extravasation injury (Table 3) also classified as a medication error (Table 2).…”

Doctors’ experiences of adverse events in secondary care: the professional and personal impact

“…[3][4][5][6][7][8][9][10] Many clinicians are also reluctant to disclose details of adverse events (see Box 1) to patients and their families. 11,12 Multiple factors are thought to contribute to this, including the psychological effects on clinicians of involvement in adverse patient safety events, a fear by them that their organisation will take a punitive approach to any investigation, and a lack of confi dence that systems will change as a result of reporting.…”

Acreditación a través del modelo de alta fiabilidad: estructura, proceso, resultado (parte 2)

“…Esta función es también suministrada por auditores médi-cos en Perú, teniendo como diferencia que estos se enfocan en fallas financieras y con menor frecuencia, en errores o problemas que resultan en lesiones de los pacientes. A su vez, existen descripciones pragmáticas en los enfoques profesionales que requieren ser considerados: 1) Los profesionales en el área de mejoramiento de calidad se enfocan en los procesos clínicos individuales para reducir la variación en los procesos (Cole & Scott, 2000;Kelly, 2013); 2) Los profesionales en el área de seguridad de los pacientes son los responsables de mejorar la efectividad organizacional para minimizar los errores y eventos adversos (Helmreich, 2000;Helmreich & Davies, 2004); 3) Los profesionales clínicos son guiados por la evidencia para aumentar la fiabilidad de los tratamientos (Fineout-Overholt, Melnyk, & Schultz, 2005); y 4) Los profesionales, en el área de riesgos, se encargan de controlar, a través de programas legales y de cumplimiento, los eventos adversos en las estrategias de identificación, reducción y mitigación (Runciman, et al, 2006;Weick, 2004). Cada ámbito profesional de manera independiente carece de suficiente sustentabilidad.…”