Nursing reported hospitalized patients adverse events: A multi-centric study in Mexico

Abstract

Introduction: Adverse events (AE) are unintended harms derived from human health attention, system factors, or clinical conditions in the patients.
Objective: To analyze factors influencing the quality of patient healthcare and safety through the review of diverse records on AEs.
Methodology: This transversal and multi-centric design study was carried out in five National Institutes of Health and a high specialty hospital. AEs in an 18 month period were studied using the SYREC 2007 instrument. Descriptive analysis, as well as assessments on the association between the preventability degree and the intrinsic, extrinsic, and system factors were all performed. Current ethical issues were observed.
Results: A total of 540 AEs were analyzed; 55.5% occurred in men; 58.7% occurred during state of
alertness; 92.6% occurred at the assigned service; 55.9% were not reported to the families; 70.5% were considered preventable; and system factors were present in 80.6% of them. A significan association between the AEs and the possibility to prevent them was found.
Discussion: The main findings were consistent with those of other international studies including: ‘‘To err is human’’, 1999, the ENEAS study in Spain, 2006, and the IBEAS prevalence study, 2010. All of these studies emphasize the need to strengthen the culture of AE-notifying and to improve the patient safety climate, as well as to promote inter-personal reflections on to the quality of care services.
Conclusions: System-related factors have the strongest influence on the occurrence of AEs, and thus, their identification becomes critical in order to enhance the quality of healthcare services.