Author/Editor		Robida, Andrej
Title		Opozorilni nevarni dogodki
Translated title		Sentinel events
Type		članek
Source		Zdrav Vestn
Vol. and No.		Letnik 73, št. 9
Publication year		2004
Volume		str. 681-7
Language		slo
Abstract		Background. The Objective of the article is a two year statistics on sentinel events in hospitals. Results of a survey on sentinel events and the attitude of hospital leaders and staff are also included. Some recommendations regarding patient safety and the handling of sentinel events are given. Methods. In March 2002 the Ministry of Health introduce a voluntary reporting system on sentinel events in Slovenian hospitals. Sentinel events were analyzed according to the place the event, its content, and root causes. To show results of the first year, a conference for hospital directors and medical directors was organized. A survey was conducted among the participants with the purpose of gathering information about their view on sentinel events. One hundred questionnaires were distributed. Results. Sentinel events. There were 14 reports of sentinel events in the first year and 7 in the second. In 4 cases reports were received only after written reminders were sent to the responsible persons, in one case no reports were obtained. There were 14 deaths, 5 of these were in-hospital suicides, 6 were due to an adverse event, 3 were unexplained. Events not leading to death were a suicide attempt, a wrong side surgery, a paraplegia after spinal anaesthesia, a fall with a femoral neck fracture, a damage of the spleen in the event of pleural space drainage, inadvertent embolization with absolute alcohol into a femoral artery and aphysical attack on a physician by a patient. Analysis of root causes of sentinel events showed that in most cases processes were inadequate. Survey. One quarter of those surveyed did not know about the sentinel events reporting system. 16% were ha ving actual problems when reporting events and 47% beleived that there was an attempt to blame individuals. (Abstract truncated at 2000 characters).
Summary		Izhodišča. Namen članka je prikazati dvoletne statistične podatke o opozorilnih nevarnih dogodkih (OND) in njihovih vzrokih, prikazati rezultate ankete o teh dogodkih in podati priporočila za zmanjševanje teh dogodkov in drugih zdravstvenih napak. Metode. V marcu 2002 je Ministrstvo za zdravje pričelo z zbiranjem poročil o opozorilnih nevarnih dogodkih v vseh bolnišnicah v Sloveniji. Opozorilne nevarne dogodke smo analizirali po kraju (bolnišnica, dejavnost), po vsebini in po poreklu vzrokov dogodka. Eno leto po vzpostavitvi poti poročanja je Ministrstvo za zdravje prikazalo izsledke o opozorilnih nevarnih dogodkih na sestanku direktorjev in strokovnih direktorjev. Istočasno smo razdelili tudi anketo o teh dogodkih, s katero smo želeli ugotovitvi, kaj vodstva bolnišnic in drugi anketiranci menijo o opozorilnih nevarnih dogodkih. Razdelili smo 100 anket in zastavili 15 vprašanj. Vzorec ankete ni bil naključen. Dobili so jo tisti, ki so bili prisotni na srečanju. Rezultati. Opozorilni nevarni dogodki. V prvem letu so bolnišnice poročale o 24 opozorilnih nevarnih dogodkih, v drugem pa o sedmih. V štirih primerih smo zaradi kasnitve prejemanja analiz in ukrepov pisno posredovali in šele nato prejeli ustrezne odgovore, v enem primeru odgovora ni bilo. Štirinajst bolnikov je umrlo, 5 od teh jih je naredilo samomor v bolnišnici, pri 6 je prišlo do smrti zaradi škodljivega dogodka, 3 smrti so ostale nepojasnene. Dogodki, ki niso končali s smrtjo, so bili poskus samomora, zamenjava strani operacije, paraplegija po spinalnem bloku, padec s postelje in zlom vratu stegnenice, poškodba vranice pri drenaži plevralnega prostora, fizični napad bolnika na zdravnika in zatekanje absolutnega alkohola v femoralno arterijo ob embolizaciji tumorske arterije. Pri analizi porekla vzrokov 21 sporočenih OND smo ugotovili, da so za te dogodke največkrat krivi neizdelani procesi. (Izvleček skrajšan pri 2000 znakih).
Descriptors		MEDICAL ERRORS RISK ASSESSMENT HEALTH POLICY QUALITY ASSURANCE, HEALTH CARE HOSPITALIZATION HOSPITAL MORTALITY PATIENT CARE TEAM QUESTIONNAIRES