Aggregate causes of adverse events and possible methods to mitigate them within healthcare: Results and lessons learned based on the reports sent to the Hungarian NEVES reporting and learning system

Abstract

In 2007, the NEVES system started its operation in Hungary. Ever since, more than 26.5 thousand adverse events reports arrived. By analysing these reports, causal research was conducted and recommendations were made to prevent these causes. Based on the results of the causal research, the identification of the most important causes of adverse events within the Hungarian healthcare settings, and the creation of recommendations on how to tackle these causes. To identify possible causes and actions that can be made, a literature survey was conducted for each area. Descriptive statistics was conducted to identify possible associations, after which Ishikawa chart was used to search for possible root-causes. Possible solutions were gathered via focus groups discussions. Summary tables were created based on the results of these focus groups. Nine main groups of causes were identified: regulation; following regulations; shortcomings of activities that should be carried out; not learning from previous events; education; human resources; communication and documentation; the usage of devices; problems with the infrastructure. The recommended solutions can be grouped into six areas: actions regarding the creation and everyday usage of regulations; organising and conducting educations; procurement based on needs; improving communications; learning from mistakes and adverse events; using motivation tools. The analysis made at the national level can be the basis to identify local circumstances and areas of improvement. This requires dedicated leadership, adequate patient safety knowledge and perspective to achieve changes and willingness to make changes. Orv Hetil. 2022; 163(6): 236-245.