Adverse Event Detection in a Hospital Clinic Ward through an Active Methodology

Abstract

INTRODUCTION: Hospital adverse events (AE) express deficiencies in the safety of inpatients. Although it is an issue widely addressed in other areas, not enough research lines have been developed at national level. The objective of this study was to measure the frequency of AE and its consequences in a hospital clinic ward in the province of Buenos Aires, and to quantify the underreporting of AE in the medical record (MR). METHODS: A descriptive study with an active methodology for AE detection was conducted. Through daily visits to the ward, the AE and the other variables were detected by direct observation of the care process and interviews with health professionals and patients. RESULTS: A high occurrence of cases was observed (70%), due in part to the methodology used and to an expanded definition of AE. The most frequent consequence in the patients was physical discomfort (65.6%), while for the hospital system it was the additional use of therapeutic resources (48.9%). The case-fatality rate due to AE was 5.3%. Only 39.7% of the cases were registered in the MR. CONCLUSIONS: The usual methodologies for the study of AE do not seem to be effective to identify all cases. Both the traditional definitions of AE and the underreporting of cases in MR underestimate this problem of hospital safety