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Inicio Journal of Healthcare Quality Research A hospital incident reporting system (2016–2019): Learning from notifier's...
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Vol. 38. Issue 2.
Pages 93-104 (March - April 2023)
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Vol. 38. Issue 2.
Pages 93-104 (March - April 2023)
Original Article
A hospital incident reporting system (2016–2019): Learning from notifier's perception on incidents’ risk, severity and frequency of adverse events
Un sistema de notificación de incidentes hospitalarios (2016-2019): aprendizaje de la percepción de los notificadores sobre el riesgo de los incidentes, la gravedad y la frecuencia de los eventos adversos
L. de la Torre-Péreza,
Corresponding author

Corresponding author.
, L. Granésb, A. Prat Marínb,c, M.J. Bertranb
a Barcelona Institute for Global Health, Barcelona, Spain
b Preventive Medicine and Epidemiology Department, Clinic Institute of Medicine and Dermatology (ICMiD), Hospital Clínic of Barcelona, Barcelona, Spain
c Medicine Department, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Incident reporting systems (IRSs) are considered safety culture promoters. Nevertheless, they have not been contemplated to monitor professionals’ perception about patient safety related risks. This study aims to describe the characteristics and evolution of incident notifications reported between 2016 and 2019 in a high complexity reference hospital in Barcelona and explores the association between notifications’ characteristics and notifier's perception about incidents severity, probability of occurrence and risk. The main analysis unit was notifications reported. A descriptive analysis was performed and taxes by hospital activity were calculated. Odds ratios were obtained to study the association between the type of incident, the moment of incident, notifiers’ professional category, reported incident's severity, probability and incidents’ calculated risk. Through the study period, a total of 6379 notifications were reported, observing an annual increase of notifications until 2018. Falls (21.22%), Medical and procedures management (18.91%) and Medication incidents (15.49%) were the most frequently notified. Departments reporting the highest number of notifications were Emergency room and Obstetrics & Gynaecology. Incident type and notifiers’ characteristics were consistently included in the models constructed to assess risk perception. Pharmaceutics were the most frequent notifiers when considering the proportion of staff members. Notification patterns can inform professionals’ patient risk perception and increase awareness of professionals’ misconceptions regarding patient safety.

Patient safety
Incident reporting system

Los sistemas de notificación de incidentes promueven la cultura de la seguridad en los hospitales. Sin embargo, no se han considerado para conocer la percepción de los profesionales sobre los riesgos relacionados con la seguridad del paciente. Este estudio pretende describir las características y la evolución de las notificaciones de incidentes comunicadas entre 2016 y 2019 en un hospital de alta complejidad de Barcelona y explorar la asociación entre las características de las notificaciones y la percepción del notificador sobre la gravedad de los incidentes, la probabilidad de ocurrencia y el riesgo. La unidad de análisis principal fueron las notificaciones comunicadas. Se realizó un análisis descriptivo y se calcularon las tasas en relación con la actividad hospitalaria. Se obtuvieron las odds ratios para estudiar la asociación entre el tipo de incidente, el momento del incidente, la categoría profesional de los notificadores, la gravedad, probabilidad y riesgo calculado del incidente. A lo largo del periodo de estudio se registraron un total de 6.379 notificaciones, observándose un incremento anual de notificaciones hasta 2018. Las caídas (21,22%), los problemas en la gestión médica y de procedimientos (18,91%) y los incidentes de medicación (15,49%) fueron los más notificados. Los departamentos que reportaron el mayor número de notificaciones fueron urgencias y obstetricia y ginecología. El tipo de incidente y las características de los notificadores se incluyeron sistemáticamente en los modelos para evaluar la percepción del riesgo. Los farmacéuticos fueron la categoría profesional más notificadora considerando el número de profesionales en plantilla. Los patrones de notificación pueden informar sobre la percepción del riesgo de los pacientes por parte de los profesionales y ayudar a detectar creencias erróneas de los profesionales acerca de la seguridad de los pacientes.

Palabras clave:
Seguridad del paciente
Sistema de notificación de incidentes


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