Near Miss analysis in a large hospital: a 5-year retrospective study Maestri, R.; Parrini, M. Souza, A.B.; Rohsig, V.
Hospital Moinhos de Vento Located in Southern Brazil, Hospital Moinhos de Vento is one of the six hospitals of excellence of the country and delivers clinical and hospital care with an emphasis in complex pathologies. surgery center intensive care maternity capacity unit 17 operation rooms 497 beds 50 50 beds 85 85 beds 23k surgeries 28k hospitalizations 4k deliveries Data from 2017
High Reliability Organizations A High Reliability Organization (HRO) is an organization that has successfully avo voided catast stroph rophe in an envir viron onme ment where re accidents can can be be exp xpected due to risk factors ors and complexi xity. SITUATIONAL AWARENESS COMMITMENT TO RESILIENCE PREOCCUPATION WITH FAILURE RELUCTANCE TO SIMPLIFY INTERPRETATIONS DEFERENCE TO EXPERTISE https://psnet.ahrq.gov/resources/resource/7076/becoming-a-high-reliability-organization-operational-advice-for-hospital-leaders.
And when this environment is a hospital?
Adverse Events Classification Incidents Patient and safety events that reached the patie ient nt whether or not there was harm envolved. E.g. Adverse rse events ts, serious us adverse rse events ts, sentine inel l events ts. Near Misses Patient safety events that did not reach the patie ient nt. Unsafe conditions Circumstances that incre rease se the probabili ility ty of a patient safety event occurring. https://psnet.ahrq.gov/primers/primer/13/Reporting-Patient-Safety-Events
Near Miss Incidents Report VASCULAR DRAINS/ DRESSING ISOLATION ACCESS TUBES MEDICATION COMMUNICATION HYGIENE AND NURSING PROCESS CONFORT CONTROLS
Objective and Methods To analyze all near miss incidents OBJECTIVE in a private, non-profit, Hospital in the South of Brazil. - Descriptive, retrospective study - Data colection was performed on August 25, 2017 METHODS - Inclusion criteria: near miss events related to medication process and patient care recorded between January 1, 2013 and August 24, 2017.
Results – number of reports 5000 30 4360* Serious adverse events and sentinel events 4500 24 24 3835 25 4000 3522 21 21 3500 20 16 16 3000 Near misses 13 13 2500 15 1927 11 11 2000 10 1500 1104 1000 5 500 0 0 2013 2014 2015 2016 2017 Year Near misses Serious adverse events and sentinel events * Jan-Aug 2017
Results – number of reports by category
Results Number of Reports Number of Near Misses by Professionals in the Medication Process
Conclusion We analyzed 12 12,939 near ar miss event nts related to the medication process and patient care recorded between January 1, 2013 and August 24, 2017. Considering the number of admissions of the period (125,430 patients) the preva evalenc lence of of reported ed near ar miss events ts was 10 10.3%. Medica icatio tion-relat elated ed near ar miss incid ident ents were the most frequent ent. Near misses associated with the recording of patient information (mainly related to fluid balance) and venous/vascular puncture were also frequent in the analyzed events. Safety ety culture lture is is well well-esta tablis lished ed and connect ected ed to to the organ anizat izatio ional cult lture in in the instit titutio ion. There is good adherence of professionals to the reporting ting system. When a near miss occur, the teams ams that at reported ted the event are always ways invo volved lved in in the desig ign and implement lementat atio ion of of strat ateg egies ies to to improve ve safety ety.
Mohamed Parrini, CEO ________________________ THANK YOU
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