Análisis de la implantación de un sistema de notificación y registro de eventos adversos en el proceso asistencial de una mutua de accidentes de trabajo

Abstract

To describe the results of a voluntary reporting system for adverse events in a Patient Safety Program of an occupational injuries mutual insurance company. In 2008 a system of notification and registration of adverse events (actual or potential) was introduced in 2008 by the Union de Mutuas, an occupational injuries insurance company with 36 health centres, and provides coverage for 259,922 workers. The reporting questionnaire covers all areas of health care provided by the mutual company. Access to the questionnaire was conducted through the intranet, was voluntary and anonymous. The notifications registered between 1 January 2009 and 31 December 2010 are analysed. A total of 16 questionnaires were completed, with a total of 205 incidents. The profile of the reporter was first-level health care (57.7%), and seniority in their job for 5-10 years. Of all the notifications, a health care cause of the incident was seen in 43.5% of cases, of which 85.9% of the incidents were preventable. Of all reported events, 71.7% were related to an ambulatory care medical centre, and only 2.4% was related to a surgical procedure. Most of the notifications were preventable incidents, and recorded by first-level medical care. The reporting questionnaire was shown to be a valid tool in our work environment for the detection of adverse events in the care process.