a 5-year retrospective study Maestri, R.; Parrini, M. Souza, A.B.; - - PowerPoint PPT Presentation

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. Data from 2017

497 beds

capacity

28k hospitalizations

intensive care unit

85 85 beds 50 50 beds

maternity

4k deliveries 17 operation rooms

surgery center

23k surgeries

High Reliability Organizations

A High Reliability Organization (HRO) is an organization that has successfully avo voided catast stroph rophe in an envir viron

• nme

ment where re accidents can can be be exp xpected due to risk factors

• rs and complexi

xity.

https://psnet.ahrq.gov/resources/resource/7076/becoming-a-high-reliability-organization-operational-advice-for-hospital-leaders.

SITUATIONAL AWARENESS PREOCCUPATION WITH FAILURE DEFERENCE TO EXPERTISE COMMITMENT TO RESILIENCE RELUCTANCE TO SIMPLIFY INTERPRETATIONS

And when this environment is a hospital?

Unsafe conditions

Circumstances that incre rease se the probabili ility ty of a patient safety event occurring.

Near Misses

Patient safety events that did not reach the patie ient nt.

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.

Adverse Events Classification

https://psnet.ahrq.gov/primers/primer/13/Reporting-Patient-Safety-Events

MEDICATION PROCESS VASCULAR ACCESS

Near Miss Incidents Report

COMMUNICATION DRESSING HYGIENE AND CONFORT ISOLATION NURSING CONTROLS DRAINS/ TUBES

Objective and Methods

To analyze all near miss incidents in a private, non-profit, Hospital in the South of Brazil.

OBJECTIVE

• Descriptive, retrospective study
• Data colection was performed on August 25, 2017
• Inclusion criteria: near miss events related to medication process and

patient care recorded between January 1, 2013 and August 24, 2017.

METHODS

Results – number of reports

* Jan-Aug 2017

1104 1927 3522 3835 4360* 24 24 21 21 16 16 13 13 11 11 5 10 15 20 25 30 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 2013 2014 2015 2016 2017

Serious adverse events and sentinel events Near misses Year

Near misses Serious adverse events and sentinel events

Results – number of reports by category

Results

Number of Near Misses in the Medication Process Number of Reports by Professionals

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

• f 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

• f strat

ateg egies ies to to improve ve safety ety.

Mohamed Parrini, CEO

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