array:20 [ "pii" => "13113634" "issn" => "1134282X" "doi" => "10.1016/S1134-282X(07)71242-3" "estado" => "S300" "fechaPublicacion" => "2007-11-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Calidad Asistencial. 2007;22:335-41" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3914 "formatos" => array:3 [ "EPUB" => 53 "HTML" => 2756 "PDF" => 1105 ] ] "itemSiguiente" => array:15 [ "pii" => "13113648" "issn" => "1134282X" "estado" => "S300" "fechaPublicacion" => "2007-11-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Calidad Asistencial. 2007;22:342-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2968 "formatos" => array:3 [ "EPUB" => 31 "HTML" => 2391 "PDF" => 546 ] ] "es" => array:10 [ "idiomaDefecto" => true "titulo" => "Análisis comparativo hospitalario del evento adverso en México: utilidad del reporte voluntario en línea" "tienePdf" => "es" "tieneTextoCompleto" => 0 "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "342" "paginaFinal" => "349" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Comparative analysis of adverse events in two hospitals in Mexico: utility of voluntary on-line" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Odet Sarabia González, Ofelia Poblano-Verástegui, Walter Tovar Vera, Francisco Garrido Latorre" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Odet" "apellidos" => "Sarabia González" ] 1 => array:2 [ "nombre" => "Ofelia" "apellidos" => "Poblano-Verástegui" ] 2 => array:2 [ "nombre" => "Walter" "apellidos" => "Tovar Vera" ] 3 => array:2 [ "nombre" => "Francisco" "apellidos" => "Garrido Latorre" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13113648?idApp=UINPBA00004N" "url" => "/1134282X/0000002200000006/v0_201308011132/13113648/v0_201308011133/es/main.assets" ] "itemAnterior" => array:15 [ "pii" => "13113633" "issn" => "1134282X" "estado" => "S300" "fechaPublicacion" => "2007-11-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Calidad Asistencial. 2007;22:327-35" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2601 "formatos" => array:3 [ "EPUB" => 32 "HTML" => 2112 "PDF" => 457 ] ] "es" => array:10 [ "idiomaDefecto" => true "titulo" => "Claves y retos en la comparación internacional de la seguridad del paciente: la experiencia del Health Care Quality Indicators Project de la OCDE" "tienePdf" => "es" "tieneTextoCompleto" => 0 "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "327" "paginaFinal" => "335" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Key challenges in comparing patient safety across countries: the experience of the OECD health care quality indicators project" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sandra García-Armesto, Edward Kelley, Niek Klazinga, Lihan Wei" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sandra" "apellidos" => "García-Armesto" ] 1 => array:2 [ "nombre" => "Edward" "apellidos" => "Kelley" ] 2 => array:2 [ "nombre" => "Niek" "apellidos" => "Klazinga" ] 3 => array:2 [ "nombre" => "Lihan" "apellidos" => "Wei" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13113633?idApp=UINPBA00004N" "url" => "/1134282X/0000002200000006/v0_201308011132/13113633/v0_201308011133/es/main.assets" ] "es" => array:13 [ "idiomaDefecto" => true "titulo" => "Notificación de eventos adversos en un hospital nacional en Lima" "tieneTextoCompleto" => 0 "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "335" "paginaFinal" => "341" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Nora Espíritu, Gliceria Lavado, Lilian Pantoja, Carmen Lam, Mónica Barrientos, Rigoberto Centeno" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Nora" "apellidos" => "Espíritu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Gliceria" "apellidos" => "Lavado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Lilian" "apellidos" => "Pantoja" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "Carmen" "apellidos" => "Lam" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 4 => array:3 [ "nombre" => "Mónica" "apellidos" => "Barrientos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 5 => array:3 [ "nombre" => "Rigoberto" "apellidos" => "Centeno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Área de Investigación. Hospital Nacional Dos de Mayo. Lima. Perú." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Oficina de Gestión de la Calidad. Hospital Nacional Dos de Mayo. Lima. Perú." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Oficina de Apoyo a la Docencia e Investigación. Hospital Nacional Dos de Mayo. Lima. Perú." "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Oficina de Epidemiología. Vigilancia epidemiológica. Hospital Nacional Dos de Mayo. Lima. Perú." "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Consultoría de servicios de salud. Organización Panamericana de Salud (OPS/OMS). Lima. Perú." "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Notification of adverse events in a national hospital in Lima" ] ] "pdfFichero" => "256v22n06a13113634pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec233267" "palabras" => array:3 [ 0 => "Eventos adversos" 1 => "Sistema de notificación" 2 => "Seguridad del paciente" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec233268" "palabras" => array:3 [ 0 => "Adverse events" 1 => "Notification systems" 2 => "Patient safety" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "Objetivo: Establecer un sistema de notificación de eventos adversos (EA) en el Hospital Nacional Dos de Mayo (HNDM). Método: Investigación operativa, centrada en la puesta en funcionamiento de un sistema de notificación voluntario, confidencial y con vigilancia activa entre el 1 de octubre de 2005 y el 31 de marzo de 2006. El modelo para el abordaje de los EA fue de carácter sistémico. Resultados: El total de egresos fue 8.964 y la cantidad de EA reportados, 347. La tasa de EA fue del 3,9% y los EA potenciales, 12 (0,13%). Los EA más detectados fueron las infecciones hospitalarias, con 241 (70%), y el servicio de neonatología es el que tiene el mayor número de casos: 47 (19,5%); entre éstos, la sepsis hospitalaria neonatal (19 casos) fue la más frecuente. La segunda causa de EA fue las reacciones adversas a medicamentos (RAM), con 49 (14,2%) casos, de los cuales 39 (79,6%) ocurrieron durante el tratamiento antirretroviral. Casi todas las notificaciones fueron obtenidas por vigilancia activa y hubo sólo 5 reportes voluntarios. Encontramos información fragmentada de otros subsistemas, como el del comité de infecciones hospitalarias, hemovigilancia, farmacovigilancia, sistema de quejas y auditorías. Se buscaron EA en las reintervenciones quirúrgicas no programadas, y se clasificaron los EA por frecuencia e impacto. Conclusiones: La tasa general de EA estimada (3,9%) es menor que la de países desarrollados cuyas condiciones sanitarias son mejores que las nuestras, lo que indica un probable subregistro. La vigilancia activa de EA e integración de subsistemas es la forma más adecuada en el momento para obtener información de EA." ] "en" => array:1 [ "resumen" => "Objective: To establish a system for notifying adverse effects (AE) at the Dos de Mayo National Hospital. Method: We performed an operative investigation of the implementation of a confidential, voluntary reporting system with active surveillance from 1 October 2005 to 31 March 2006. A systems-based model was used for the management of AE. Results: Among a total of 8,964 hospital admissions, 347 AE were reported. The rate of AE was 3.9% and there were 12 near misses (0.13%). The most frequent AE were nosocomial infections 241 (70%). The highest number of cases (47 [19.5%]) occurred in the neonatology department and the most frequent condition was neonatal sepsis (19 cases). The second most frequent AE were adverse drug reactions, amounting to 49 cases (14.2%). Of these, 39 (79.6%) were caused by antiretroviral therapy. Almost all notifications were obtained by active surveillance and there were only five voluntary reports. We found additional information in fragmented subsystems such as the nosocomial infections board, blood surveillance, pharmacology surveillance, the complaints system and audits. In addition, we searched for AE in non-elective surgical re-interventions. All AE were classified by frequency and impact. Conclusions: The estimated overall rate of AE (3.9%) was lower than that in developed countries with better health conditions, suggesting a possible under-reporting bias. We infer that active surveillance of AE coupled with integration of subsystems is currently the most appropriate way to obtain information on AE." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "256v22n06-13113634tab01.gif" "imagenAlto" => 1136 "imagenAncho" => 780 "imagenTamanyo" => 95082 ] ] ] ] ] "descripcion" => array:1 [ "es" => "Hoja de notificación para la seguridad del paciente." ] ] 1 => array:6 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "256v22n06-13113634tab02.gif" "imagenAlto" => 773 "imagenAncho" => 1164 "imagenTamanyo" => 43243 ] ] ] ] ] ] 2 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "256v22n06-13113634tab03.gif" "imagenAlto" => 551 "imagenAncho" => 561 "imagenTamanyo" => 18988 ] ] ] ] ] ] 3 => array:6 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "256v22n06-13113634tab04.gif" "imagenAlto" => 510 "imagenAncho" => 564 "imagenTamanyo" => 17549 ] ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "World Alliance for Patient Safety, Forward Programme 2005. 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Información de la revista
Vol. 22. Núm. 6.
Páginas 335-341 (noviembre 2007)
Vol. 22. Núm. 6.
Páginas 335-341 (noviembre 2007)
Acceso a texto completo
Notificación de eventos adversos en un hospital nacional en Lima
Notification of adverse events in a national hospital in Lima
Visitas
5657
Nora Espíritua, Gliceria Lavadob, Lilian Pantojac, Carmen Lamd, Mónica Barrientosd, Rigoberto Centenoe
a Área de Investigación. Hospital Nacional Dos de Mayo. Lima. Perú.
b Oficina de Gestión de la Calidad. Hospital Nacional Dos de Mayo. Lima. Perú.
c Oficina de Apoyo a la Docencia e Investigación. Hospital Nacional Dos de Mayo. Lima. Perú.
d Oficina de Epidemiología. Vigilancia epidemiológica. Hospital Nacional Dos de Mayo. Lima. Perú.
e Consultoría de servicios de salud. Organización Panamericana de Salud (OPS/OMS). Lima. Perú.
Este artículo ha recibido
Información del artículo
Objetivo: Establecer un sistema de notificación de eventos adversos (EA) en el Hospital Nacional Dos de Mayo (HNDM). Método: Investigación operativa, centrada en la puesta en funcionamiento de un sistema de notificación voluntario, confidencial y con vigilancia activa entre el 1 de octubre de 2005 y el 31 de marzo de 2006. El modelo para el abordaje de los EA fue de carácter sistémico. Resultados: El total de egresos fue 8.964 y la cantidad de EA reportados, 347. La tasa de EA fue del 3,9% y los EA potenciales, 12 (0,13%). Los EA más detectados fueron las infecciones hospitalarias, con 241 (70%), y el servicio de neonatología es el que tiene el mayor número de casos: 47 (19,5%); entre éstos, la sepsis hospitalaria neonatal (19 casos) fue la más frecuente. La segunda causa de EA fue las reacciones adversas a medicamentos (RAM), con 49 (14,2%) casos, de los cuales 39 (79,6%) ocurrieron durante el tratamiento antirretroviral. Casi todas las notificaciones fueron obtenidas por vigilancia activa y hubo sólo 5 reportes voluntarios. Encontramos información fragmentada de otros subsistemas, como el del comité de infecciones hospitalarias, hemovigilancia, farmacovigilancia, sistema de quejas y auditorías. Se buscaron EA en las reintervenciones quirúrgicas no programadas, y se clasificaron los EA por frecuencia e impacto. Conclusiones: La tasa general de EA estimada (3,9%) es menor que la de países desarrollados cuyas condiciones sanitarias son mejores que las nuestras, lo que indica un probable subregistro. La vigilancia activa de EA e integración de subsistemas es la forma más adecuada en el momento para obtener información de EA.
Palabras clave:
Eventos adversos
Sistema de notificación
Seguridad del paciente
Objective: To establish a system for notifying adverse effects (AE) at the Dos de Mayo National Hospital. Method: We performed an operative investigation of the implementation of a confidential, voluntary reporting system with active surveillance from 1 October 2005 to 31 March 2006. A systems-based model was used for the management of AE. Results: Among a total of 8,964 hospital admissions, 347 AE were reported. The rate of AE was 3.9% and there were 12 near misses (0.13%). The most frequent AE were nosocomial infections 241 (70%). The highest number of cases (47 [19.5%]) occurred in the neonatology department and the most frequent condition was neonatal sepsis (19 cases). The second most frequent AE were adverse drug reactions, amounting to 49 cases (14.2%). Of these, 39 (79.6%) were caused by antiretroviral therapy. Almost all notifications were obtained by active surveillance and there were only five voluntary reports. We found additional information in fragmented subsystems such as the nosocomial infections board, blood surveillance, pharmacology surveillance, the complaints system and audits. In addition, we searched for AE in non-elective surgical re-interventions. All AE were classified by frequency and impact. Conclusions: The estimated overall rate of AE (3.9%) was lower than that in developed countries with better health conditions, suggesting a possible under-reporting bias. We infer that active surveillance of AE coupled with integration of subsystems is currently the most appropriate way to obtain information on AE.
Keywords:
Adverse events
Notification systems
Patient safety
El Texto completo está disponible en PDF
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